






































O0 x 






A TREATISE 



ORTHOPEDIC SURGERY 



7 



BY 



ROYAL WHITMAN, M.D. 



INSTRUCTOR IS ORTHOPEDIC SURGERY IN THE COLLEGE OF PHYSICIANS AND SUKGF.ONS OF COLUMBIA 

UNIVERSITY, NEW YORK : ASSOCIATE SURGEON TO THE HOSPITAL FOR RUPTURED AND 

CRIPPLED; ORTHOPEDIC SURGEON TO THE HOSPITAL OF ST. JOHN'S GUILD; 

CHIEF OF THE ORTHOPEDIC DEPARTMENT OF THE 

VANDERRILT CLINIC. 

MEMBER OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND; MEMBER AND SOMETIME PRESIDENT OF 

THE AMERICAN ORTHOPEDIC ASSOCIATION ; CORRESPONDING MEMBER OF THE BRITISH 

ORTHOP.EDIC SOCIETY ; MEMBER OF THE NEW YORK SURGICAL SOCIETY', ETC. 



SECOND EDITION, REVISED AND ENLARGED 



ILLUSTRATED WITH FIVE HUNDRED AND SEVEN ENGRAVINGS 




LEA BROTH ERS & CO. 

P H I L A I) E L V B I A A N D N E W V R K 
1 903 



I 



COPY B. 1 


7/ 

- 



Dg to the Act of Congress, in the year 1903, by 
LEA BROTHERS & CO., 
in the Office of the Librarian of Congress. All rights reserved. 



IN, PRINTER 



TO 



VIRGIL P. GIBXEY, M.D., LL.D. 



THIS VOLUME IS INSCRIBED 



AS A TOKEN OF FRIENDSHIP ASSURED BY LONG ASSOCIATION 



AND OF APPRECIATION OF HIS EFFORTS 



FOR THE ADVANCEMENT OF 



ORTHOPEDIC SURGERY 



PREFACE TO THE SECOND EDITION, 



The author has utilized the opportunity offered by the early 
exhaustion of the first edition to thoroughly revise the book; 
and he trusts that in its present form it fairly represents this 
department of medicine at the date of issue. The consideration of 
new subjects, the more extended description of others, and the 
addition of illustrative figures have resulted in a material enlarge- 
ment of the book, but the general characteristics of the first edition 
have been retained. 

28 Lexington Avenue, New York, October, 1903. 



FROM THE PREFACE TO THE FIRST EDITION. 



In the preparation of this volume it has been the purpose of 
the author to present as adequately as might be the practice of 
Orthopedic Surgery of the present day. The student of this 
subject is especially concerned with the mechanics of the human 
machine, with its development, with its capacity at different 
periods of life and under varying conditions, and with those 
affections that lead to deformity or that otherwise impair its use- 
fulness. He is concerned, moreover, not only with the local and 
immediate effects of disease or disability, but with its general 
influence upon the entire mechanism, and with its ultimate con- 
sequences as well. 

Orthopedic Surgery occupies a broad field and one of very 
great and general interest. Its most distinctive advance in recent 
years lias been toward the prevention of deformity, an advance 



PREFACE. 

thai has been made possible by the better understanding of its 
predisposing and exciting causes. As a natural consequence, 
treatment baa become more direct, more simple, and more effec- 
tive. 1 1 baa been the purpose of the author to emphasize this 
aspect of the subject, which is of the greatest importance to the 
pal practitioner, who so often has the opportunity to recognize 
disease or disability in its ineipiency, when its progress may be 
checked by timely treatment. 

He has endeavored to present Orthopedic Surgery as far as 
possible objectively, and in a manner that has proved acceptable 
students and practitioners in clinical teaching. Thus the 
selection of each subject and the space that has been allotted to 
it bas been determined primarily by its relative importance in 
the actual work of orthopedic clinics. He has been at some 
pain-, also, to outline methods of examination, to explain the 
phenomena of the symptoms and so to describe and to illustrate 
the causes and effects of disease and disability as to indicate, in 
natural sequence, the principles of treatment; but the particular 
methods of the application of these principles, which have been 
described in detail, are always those that have been tested by 
■ ii.il experience. 

Although this book is designed particularly for students and 
practitioners of medicine, the author has included statistical and 
other data which he hopes may prove of interest to his fellow- 
workers in this special Held. 

The author desires to express his obligation to the gentlemen 
who he- assisted him in the collection of statistics, and other- 
names are mentioned in the text; to Dr. L. W. Ely 
and to Mr. \\ . P. Agnew for timely photographs, and especially 
to the Trustees of the Hospital for Ruptured and Crippled, for 
the facilities thai have been afforded him in the preparation of 
this w<.rk. 



CONTENTS. 



CHAPTER I. 



TUBERCULOUS DISEASE OF THE SPINE. 

PAGE 

Description — Pathology — Etiology — Statistics — General prognosis — 
Symptoms — Physical examination — Contour and flexibility of the 
spine — Divisions of the spine — Landmarks — The differential diagno- 
sis of disease in the lower, middle, and upper regions of the spine — 
Treatment by horizontal fixation and overextension — by braces — 
by plaster jackets — by other means. The selection and adaptation 
of treatment for disease of the different regions of the spine. The 
complications of tuberculous disease of the spine — Abscess— course 
— symptoms — treatment. Paralysis — course — symptoms — treat- 
ment. Forcible correction of deformity — (Calot's operation)— 
Gradual correction of deformity — Recurrence of Disease — Second- 
ary deformities — Recapitulation. . . . . . .17 

CHAPTER II. 

NON-TUBERCULOUS AFFECTIONS OF THE SPIXE. 

Syphilis — Malignant disease — Osteomyelitis, acute and chronic — Actino- 
mycosis — Injury — Traumatic spondylitis — Rhachitic spine — Ty- 
phoid spine — Gonorrheal arthritis of the spine — Arthritis — Spon- 
dylitis deformans, varieties — Osteitis deformans — Neurotic spine — 
Hysterical spine — Pain in the back — Spondylolisthesis — Sciatic 
scoliosis — Disease and injury at the sacroiliac articulation . . 129 

CHAPTER III. 

LATERAL CURVATURE OF THE SPIXE. 

Description — habitual and fixed deformity, rotation and lateral devia- 
tion. Pathology — Etiology — Statistics — Varieties — Distribution 
and effects of deformity — Symptoms — Diagnosis- Prognosis— Pre- 
vention of deformity — Desks, chairs — Principles of treatmenl 
Treatment — by exercises — general exercises - heavy exercises — 
special exercises -Supports. Forcible correct ion of deformity — 
Adjuncts in treatment Duration of treatmenl . . .11!) 

CHAPTER IV. 

DEFORMITIES OF THE SPINE (CONTINUED). DEFORMITIES OF ini: < B 
FUNCTIONAL PATHOGENESIS OF DEFORMITY. 

Varieties in contour of the -pin'- The round and I he Sal back Kyphosi 
— Lordosis —Treatment Congenital elevation of the scapula — 



CONTENTS. 



Absence of vertebrae -Flat chest — Pigeon chest — Funnel chest — 
Minor deformities — Absence of ribs — Defective formation of the 
pectoral muscles — Absence or defect of. the clavicle — Acquired lux- 
ation or subluxation of the clavicle — Asymmetrical development — 
Tables of height, weight, and circumference of the chest — Func- 
t ional pat oogenesis of deformity — (Wolff's law) — Atrophy of bone . 223 

CHAPTER V. 

TUBERCULOUS DISEASE OF THE BONES AND JOINTS. 

Predisposition — Mode of infection — Latent tuberculosis — Local predis- 
position — Statistics — distribution of disease — location — side affected 
— sex — age. Pathology — Varieties of disease — synovial — arbores- 
cent synovial form— lipoma arborescens — rice bodies — caries sicca — 
Progress and method of repair — Prognosis — Treatment — operative 
and mechanical — by drugs — local applications — X-ray — Active and 
passive congestion — venous stasis (Bier's treatment) . . . 243 

CHAPTER VI. 

NON-TUBERCULOUS DISEASES OF THE JOINTS. 

Syphilitic disease of joints — Gonorrhoeal arthritis — Other forms of in- 
fectious arthritis — Acute epiphysitis — acute osteomyelitis — Sub- 
acute osteomyelitis — Osteoarthritis and rheumatoid arthritis — Va- 
rieties — Treatment — Still's disease — Haemophilia — Haemarthrosis 
— Scorbutus — Charcot's disease — Other forms of arthropathy — An- 
chylosis . . 263 

CHAPTER VII. 

TUBERCULOUS DISEASE OF THE HIP-JOINT. 

Pathology- Statistics— Symptoms — Physical signs, distortion, apparent 
lengthening, apparent shortening. Causes of distortion — Atrophy — 
Causes of actual shortening — Measurements — Lovett's table — 
Kingsley's table — Explanation of physical signs — Differential diag- 
nosis — Principles of treatment — The traction hip brace — The 
Thomas brace — The plaster bandage — Various methods of reducing 
deformity— Comparison of methods of treatment — The long hip 
splinl -Other forms of apparatus — Bilateral hip disease — Hip dis- 
m infancy — Hip disease in adult life — Abscess — statistics — 
t reatmenl -( )perative treatment — exploration — excision — reduc- 
tion of resistant deformity — Prognosis, mortality, functional results 
Secondary deformities of hip disease — Treatment — Finalresults . 291 

CHAPTER VIII. 

\n\ rUBERCULOUS LPPBCTIONS OF THE HIP-JOINT. 

-Traumatisms at the hip — Acute infectious arthritis — Sub- 
acute arthritis — Spontaneous dislocation — Gonorrhoeal arthritis — 
Ebctra-articular disease Malignant disease at the hip-joint — Cysts 
of the femur — Arthritis deformans ...... 391 



CONTENTS. j x 

CHAPTER IX. 

TUBERCULOUS DISEASE OF THE KNEE-JOINT. 

PAGE 

Pathology — Etiology — Statistics — Symptoms, primary and secondary 
distortions — Shortening and lengthening — Diagnosis — Different inl 
diagnosis— Treatment — Reduction of deformity — Forms of braces 
— Accessories in treatment — Extra-articular disease — Abscess — 
Operative treatment — arthrectomy — excision, amputation — Prog- 
nosis — mortality — functional results — General conclusions . . 399 

CHAPTER X. . 

NON-TUBERCULOUS AFFECTIOXS OF THE KNEE-JOINT. 

Injury in childhood — Synovitis — Infectious arthritis — Osteoarthritis — 
Prepatellar bursitis — Pretibial bursitis — Injury of tibial tubercle — 
Bursa? and cysts in the popliteal region — Internal derangement of 
the knee-joint — Acquired genu recurvatum — Congenital genu reeur- 
vatum — rudimentary or absent patella — Congenital displacement 
of patella — Slipping patella — Elongation of the ligamentum patellae 
— Snapping knee — Congenital contraction at the knee — General 
contractions ......... 427 



CHAPTER XL 

DISEASES AXD IXJURIES OF THE ANKLE-JOINT. 

Tuberculous disease — Pathology — Etiology — Statistics — Symptoms — 
Diagnosis — Treatment — Prognosis — Tuberculous disease of the 
tarsus — Statistics — Treatment — Sprain of the ankle— Chronic sprain 
— Tenosynovitis — Other affections of the ankle-joint . . 440 

CHAPTER XII. 

DISEASES AXD IXJURIES OF THE ARTICULATIONS OF THE 
UPPER EXTREMITY. 

Tuberculous disease of the shoulder-joint — Pathology — Statistics 
Symptoms — Treatment — Prognosis — Tuberculous disease ot the 
elbow-joint — Pathology— Statistics — Symptoms— Treatment— Prog- 
nosis — Tuberculous disease of the wrist-joint — Symptoms — Treat- 
ment — Prognosis — Spina ventosa — Periarthritis at the shoulder- 
joint — Chronic bursitis at the shoulder— Sprain of the wrisl 
Acute and chronic tenosvnovitis at the wrist . 157 



CHAPTER XIII. 

DEFORMITIES OF THE UPPER EXTREMITY. 

Congenital dislocation of the shoulder — Treatment Obstetrical paral- 
ysis— Recurrent dislocation of the shoulder— Congenital deformities 
of the elbow— Cubitus valgus— Cubitus varus Subluxation ot tli«' 
wri-T —Congenital deformitiesal the wrist —Club-hand Varieties 



CONTENTS. 



Treatment Club-hand associated with defective development — 
Congenita] contraction of the fingers Webbed fingers — Congenital 
displacement of phalanges Trigger finger Mallet finger — Base- 
ball finger Dupuytren's contraction ...... 472 



CHAPTER XIV. 

CONGENITAL \M> ACQUIRED AFFECTIONS LEADING TO GENERAL 

DISTORTIONS. 

R ha chilis -Etiology— Pathology — Symptoms, deformities — Prognosis — 
Treatment — " Late rickets" — Chondrodystrophia — Infantile scor- 
butus 1'ragilitas ossium — Osteomalacia — Osteitis deformans — 
Secondary hypertrophic osteo-arthropathy— Acromegalia . 486 



CHAPTER XV. 

CONGENITAL DISLOCATION OF THE HIP AND COXA VARA. 

Congenital dislocation of the hip-joint — Statistics — Pathology — Etiology 
Symptoms, unilateral, bilateral — Anterior — Supracotyloid — Diag- 
nosis- -Differential diagnosis — Treatment — the Lorenz operation — 
1 details and modifications — Prognosis — Treatment of older subjects 
—Treatment in infancy — The open operation — Arthrotomy — the 
intermediate operation — secondary osteotomy — Review of treat- 
ment — Congenital subluxation of the hip — Snapping hip — Palliative 
t reatment — Coxa vara — Pathology — Etiology — Statistics — Symp- 
toms, u n i la i era!, bilateral — Diagnosis — Treatment — mechanical — 
operal ive— Forcible abduction — Osteotomy — Cuneiform — Linear — 
Fracture of the neck of the femur — Traumatic separation of the 
epiphysis of the head of the femur — Fracture in adult life — Coxa 
valga 502 

CHAPTER XVI. 

DEFORMITIES OF THE BONES OF THE LOWER EXTREMITY. 

Bow-leg Knock-knee Statistics Etiology — The outgrowth of defor- 
mity Genu valgum Description — Attitudes — Secondary defor- 
mities Gail Unilateral deformity — Pathology — Treatment — ex- 
pectanl mechanical operative Genu varum, varieties — Symp- 
tom- Treatment Expectant mechanical — operative — Anterior 
bow-leg General rhachitic distortions ..... 553 



CHAPTER XVII. 

DISEASES OF THE NERVOUS SYSTEM. 

Acute anterior poliomyelitis Pathology Etiology Statistics — Symp- 
tom- Diagnosis Prognosis— Causes of Deformity — Deformity in 
various regions Subluxation Retardation of growth — Principles 
ofTreatmenl Treatment, mechanical, operative .... 583 



COXTEXTS. xi 

CHAPTER XVIII. 

DISEASES OF THE NERVOUS SYSTEM (CONTINUED). 

PAGE 

Cerebral paralysis of childhood — Description — Distribution — Ejt tology — 
Pathology — Symptoms — Congenital paralysis — Acquired paralysis 
— Hemiplegia — Paraplegia — Treatment — Prognosis — Spastic spinal 
paraplegia — Progressive muscular atrophy — Varieties — Sympt cms 
— Hereditary ataxia — Neuritis — Hysterical and functional affec- 
tions of the joints — '"Hysterical" hip — Differential diagnosis — 
"Hysterical" deformities — "Hysterical" club-foot — " Hysterical" 
scoliosis — Neurotic joints . . . ... . . GOO 

CHAPTER XIX. 

CONGENITAL AXD ACQUIRED TORTICOLLIS. 

Description — Statistics — Congenital torticollis — Etiology — Hematoma 
of the sternomastoid muscle — Acquired torticollis — Varieties — 
Acute torticollis — Etiology — Symptoms — Diagnosis — Treatment of 
chronic torticollis — mechanical, operative — Treatment of acute 
torticollis — Spasmodic torticollis — Etiology — Pathology — Treat- 
ment — Exceptional forms of torticollis — paralytic — diphtheritic — 
cervical opisthotonos, rhachitic — ocular — psychical . . 025 

CHAPTER XX. 

DISABILITIES AXD DEFORMITIES OF THE FOOT. 

General description of the foot and of its functions, the arches, the foot 
as a passive support, in activity — Improper postures — Movements 
— Function of the muscles — Strength of the muscles — The foot as a 
mechanism — The weak foot or so-called flat-foot — Description — 
Anatomy — Pathology — Etiology — Statistics — Symptoms — Diagno- 
sis — Varieties — Weak foot in childhood — Treatment, preventive — 
Exercises — Support — Construction of brace — The rigid weak foot — 
Forcible correction of deformity — Subsequent treatment— Adjuncts 
in treatment — Operative treatment . ( 'l~ 



CHAPTER XXI. 

DISABILITIES AND DEFORMITIES OF THE FOOT (CONTINUED). 

The hollow foot — Varieties and treatment Anterior metatarsalgia 
Morton*- neuralgia — Etiology — Treatment Aehillobursitis 
Strain of the tendo Achillis Calcaneobursitis Plantar aeuralgia 
— Eiythromelalgia — Hallux rigidus Painful greal toe Hallux 
varus— Pigeon toe- Hallux valgus Hammer toe Overlapping 
- -Fracture of metatarsus Exostoses Displacement of the 
peronei tendons Shoes, effects of improper ahoes Demonstra- 
tion of the proper shoe- Sock* ..... 699 



Xll CONTENTS. 

(HAITI;!; XXII. 

1. 1 I ORM] riES OP THE FOOT. 

PAGE 

Talipes Description Varieties Statistics of talipes, congenital and 
acquired Relative frequency of the different varieties — Congenital 
talipes Etiology Anatomy Symptoms — Principles of treatment 
of infantile club-foot Treatment — mechanical — by plaster ban- 
dage by braces restoration of function — supervision — Treatment 
in older subjects forcible manual correction — tenotomy — Wolff's 
treatment, reduction of deformity by wrenches — Phelps' operation 

Operations on the bones A.stragalectomy — Osteotomy — Me- 
chanical treatmenl Other varieties of congenital talipes — varus 

equinus calcaneus valgus — equinovalgus — calcaneovalgus — 
calcaneovarus equinocavus — valgocavus — Congenital talipes as- 
sociated with defective development — with absence of fibula — with 
absence of tibia— with detective formation of the foot — Constricting 
bands Congenital amputation — Congenital oedema — Spina bifida 
and talip^ 733 

CHAPTER XXIII. 

DEFORMITIES OF THE FOOT (CONTINUED). 

Acquired tali] >es — Etiology — Diagnosis — Talipes equinus — Description — 
l.i i< .1. <-s\ Symptoms — Treatment — mechanical — operative Talipes 
calcaneus -Description, development of deformity — Symptoms — 
Treatmenl — mechanical, operative — Talipes calcaneo varus and 
calcaneovalgus— Talipes equinovarus and talipes equinovalgus — 
Talipes valgus -Traumatic valgus — Other varieties of acquired 
talipes— Tendon transplantation in the treatment of paralytic talipes 
Tendon transplantation and arthrodesis — Tendon splicing — 
Arthrodesis and other procedures ...... 794 



ORTHOPEDIC SURGERY. 



CHAPTER I. 

TUBERCULOUS DISEASE OF THE SPINE. 

Synonym. Pott's disease. 

Pott's disease is a chronic destructive ostitis of the bodies of 
the vertebras, the anterior or weight-supporting portion of the 
spinal column. As the disease progresses the spine bends at the 
weakened point, and the upper part, sinking downward and for- 
ward, throws into relief the spinous processes at the seat of the 
disease ; thus an angular posterior projection is formed. It is called 
Pott's disease because such deformity, slow in formation, accom- 
panied by pain and sometimes by paralysis, was first described 
accurately by Percival Pott, in 1779. Angular deformity is, 
however, simply the evidence of destruction of a portion of the 
anterior part of the vertebral column. Thus it might be the 
result of fracture, or of the erosion of an aneurism, or of malig- 
nant disease, or syphilis, or other pathological process; but 
deformity from such causes is not now included under Pott's dis- 
ease, nor is the term now synonymous with deformity. In the 
modern sense it signifies tuberculous disease of the bodies of the 
vertebra?, of which the early symptoms may be detected and of 
which the deforming effects may be checked and even prevented 
by proper treatment. 

The compression and collapse of the affected parts cause the 
characteristic angular projection at the seat of the disease (Fig. 2). 
If one vertebral body is destroyed the projection will be sharp ; if 
several are implicated it will be less angular, and if one side of a 
body breaks down before the other there may be a lateral as well 
as a posterior distortion. 

The size of the deformity and its effect upon the individual 
depend in <_>reat degree upon its situation. If the disease Is at 
either extremity of the spine the angular projection must be small, 
because so little of the column remains beyond the destructive 

2 



is 



ORTHOPEDIC SURGERY. 



Fig. 1. 



process; in other words, the area of the spine directly involved 
in the deformity is small compared to that which is free from dis- 
ease (Fig. 5). Bui If the middle of the spine is affected, the 
opportunity for deformity is great, because the entire column may 
enter Into the formation of the angular kyphosis. In such cases 
the internal organs arc compressed and the effect upon the vital 
mechanism is disastrous ( l^io. 23). 

Pottos disease, as contrasted with tuberculosis of other bones 
and joints, is peculiar in that it is concealed from view, in that 
direct surgical intervention is of compara- 
tively little avail, in that it lies in close 
proximity to important parts, the spinal cord 
behind and the vital organs in front, and, 
finally, in that the effects of the disease and 
deformity are not limited to the parts di- 
rectly involved, but influence, to a greater 
or less degree, the entire mechanism of the 
body. 

Pathology. The minute changes that 
characterize tuberculosis of bone in general 
are described in Chapter V. 

The first indication of the disease is usually 
found in the anterior part of a vertebral body 
just beneath the fibroperiosteal layer of the 
anterior longitudinal ligament. From this 
point the granulation tissue advances along 
the front of the spine and, following the 
course of the bloodvessels, it invades and 
destroys the adjacent vertebral bodies. In 
other instances the disease may begin in the 
interior of a vertebral body, most often in 
several minute foci near the upper or lower 
epiphysis. These coalescing, gradually en- 
Large, forming a cavity, surrounded for a 
time by unbroken cortical substance, which, 
becoming weaker, collapses under the pressure of the superin- 
cumbent weight Occasionally the disease advances beneath the 
anterior ligamenl without implicating deeply the substance of the 
bone — a form of tuberculous periostitis, a spondylitis superficialis." 
The intervertebral disks appear to offer some resistance to the 
extension of the disease from one vertebra to another, but when 
the hone |g destroyed on cither side they quickly disintegrate and 




ictlon of the bodies 

Of the Ant, Second and third 

lnmbax vertebra— with the 
resulting deformity. | m«'- 



TUBERCULOUS DISEASE OF THE SPIXE. 



19 



disappear. The posterior part of the spinal column usually 
remains free from disease, with the exception of the pedicles and 
articulations that may be in direct contact with the tuberculous 
process. In rare instances the disease may begin in a lamina or 
spinous process, or one of the small joints may be primarily 

Fig. 2. 









I 




IK 






r^H 


^mxfo&zt*'' 


i >-*B 






1 . & J^S 



Pott's disease. 

involved; but such forms of local tuberculosis would hardly be 
classed as Pott's disease unless the anterior part of the spine were 
implicated also. 

The course and outcome of the disease depends upon its type. 
in one instance the area of primary, infection is small and the local 
resistance is sufficient to check its further progress, so that cure 



20 ORTHOPEDIC SURGERY. 

without deformity may follow. In another the disease is inactive 
and the granulation tissue undergoes a fibroid transformation or 
becomes ossified. In such oases deformity may appear and 
slowly increase, practically without symptoms. In most instances, 
however, the tuberculous granulations advance more rapidly, 
destroying the bone or other tissue with which they come in con- 
taci ; the usual retrograde metamorphosis to cheesy degeneration 
follows, and very frequently liquefaction or abscess formation. 
This latter complication may be dependent upon secondary infec- 
tion, hut the liability to abscess is very much increased by irritation 
or injury, and it is decreased by absolute rest of the diseased part. 

As a rule, in those cases of moderate severity that come to 
autopsy during the progressive stage of the disease, one finds, on 
dividing the thickened tissues in front of the spine, a cavity, the 
walls of which are lined with tuberculous granulations in various 
stages of degeneration, and containing puriform fluid. The 
adjoining vertebral bodies present a worm-eaten appearance, and 
one or more of them is partially destroyed. Small fragments of 
necrosed bone and "bone sand" may be present, together with 
larger masses of degenerated tissue, and occasionally sequestra of 
considerable size may be found. 

In other instances the disease may begin in the posterior part 
of a vertebral body, or it may extend backward as well as for- 
ward, and, forcing its way into the vertebral canal, it may press 
upon the spinal cord and involve its coverings, and thus cause 
paralysis <>f the parts below. Less often pressure on the cord may 
be due to the presence of an abscess or to a projecting fragment 
of bone. The calibre of the spinal canal may be constricted 
somewhat by the pressure of the superincumbent weight upon the 
softened and thickened tissues at the seat of disease; but, as a 
rule, its capacity is not directly lessened by the angular distortion, 
nor does the decree of deformity directly influence the frequency 
<.f paralysis. 

Although the disease may begin in multiple primary foci of 
infection over an extended area, or in two or more distinct regions 
of the -pine simultaneously, yet clinical observation seems to show 
that it i-, in mosi instances, originally confined to one or two 
adjacent bodies. From this central point the disease may extend 
in either direction until half the spine may be implicated; but in 
ordinary cases the final area of deformity and rigidity shows that 
from three to sis bodies arc more or less involved before cure is 
established. 



TUBERCULOUS DISEASE OF THE SPINE. 



21 



If the disease is limited in extent, the eroded surfaces of the 
adjoining vertebrae may come into direct contact, but if several 
vertebral bodies have been destroyed the upper portion of the 
spine as it sinks downward is often displaced backward so that 
the anterior aspect of one or more of the upper segments may be 



Fig. 



Fig. 4. 




P 



@^ 



Destruction of the bodies of the third, 
fourth, fifth, sixth, aud seventh dorsal ver- 
tebrae ; partial destruction of three others. 
(Menard.) 



The deformity corrected BhowlDg the area 
of the destructive process (M6nard.) 



apposed to the superior surface of the firsl body of the Lower sec- 
tion (Fig. 3). Lese often there may be forward displacement 
of the upper part upon the lower (Fig. 1). 

At all stages of the disease resistance to it- progress and efforts 



<)iyru<)i>i:i)ic smaERY. 

at repair are evident in the affected parts. When this resistance 
overbalances the tendency to degeneration, cure follows. 

Repair is accomplished occasionally by contact and solid union 
of the adjoining surfaces of softened bone; but usually the 
anchylosis is in part fibrous, in part cartilaginous, and in part 
bony, and this union may be further strengthened by a callous 
formal i«>n Erom the thickened tissues about the seat of the disease. 
In many instances the articular processes, the pedicles and laminae, 
become anchylosed before repair has advanced appreciably in the 
anterior portion of the column. 

( Jure may be absolute, as when no vestige of the disease remains ; 
it may be practically assured, as when the diseased products 
undergo calcareous degeneration and are shut in by a layer of solid 
bone. In other instances the disease becomes quiescent or but 
-lowly advances, showing its presence by exacerbations of pain 
or by the formation of an abscess, long after active symptoms 
have ceased. 

Etiology. The etiology of tuberculosis of the spine does not 
differ from that of tuberculosis of other bones; the subject is con- 
sidered in ( 'liapter V. 

Relative Frequency. Tuberculosis of the spinal column is more 
common than of any other single bone or joint, as might be 
expected from it- greater area. This is illustrated by the statistics 
of tuberculous disease treated in the out-patient department of the 
Hospital for Ruptured and Crippled, New York, during a period 
of fifteen years, L885-1899 : 

Tuberculosis of the spine 3207 cases. 

" the hip 2230 " 

" other joints inclusive 2408 " 

Also by similar statistics of the Boston Children's Hospital, 
for a longer period, L869-1893 : 

Tuberculosa of the spine 1864 cases. 

" " hip, knee, ankle, shoulder, elbow, and 

wrist combined 1856 " 

Age. Pott's disease, although far more frequent in the middle 
period of childhood, from the third to the tenth year, may occur 
at any time from earliest infancy to extreme old age. 

hi a aeries of L259 consecutive cases of tuberculosis of the 
-pine collected from the records of the out-door department of 
the Hospital for Ruptured and Crippled, New York, analyzed 
l>y Drs. K. T. Frank and C. Gunter, the ages of the patients 



TUBERCULOUS DISEASE OF THE SPINE. 23 

at the supposed time of onset of the disease appeared to be as 

follows : 



Less than 1 year 38 = 3.1 per cent. 

Between 1 and 2 years 176 = 14.2 " 

3 " 5 " 627 = 50.2 " 

6 " 10 " 234 = 18.3 " 

" 11 " 20 " 89 = 7.2 

21 " 30 " ' . 43 = 3.5 " 

31 " 50 " 31 = 2.6 

Over 50 " 11 = 0.8 " 

The youngest patient was two months old, the oldest seventy-one 
years. 

Thorndike, 1 of Boston, from the records of the Boston Chil- 
dren's Hospital for thirteen years, 1883 to 1896, collected 115 
cases of tuberculosis of the spine in children of two years or 
less. Seven of these were less than six months, and twenty were 
under one year in age. 

Howard Marsh 2 has called attention to Pott's disease of 
the aged, and cites three cases in subjects of sixty or more years 
of age. 

Sex. Sex exercises comparatively little influence on the liability 
to disease of this region. Of 3797 cases collected by Mohr, Gib- 
ney, Fischer, Taylor, and Bradford and Lovett, quoted by Hoffa, 
2045 were in males and 1752 were in females. Of 1367 cases 
collected by Frank and Gunter, 708 (52 per cent.) were in males 
and 659 (48 per cent.) were in females; and in 2455 cases tabu- 
lated by Knight, 1329 were in males and 1126 in females. Of 
these combined cases from the Hospital for Ruptured and Crippled, 
3822 in number, 53.2 per cent, were in males and 46.8 per cent, 
in females. 

The Situation of the Disease. The dorsolumbar section of 
the spine is most often affected. Cervical disease is comparatively 
infrequent. 

In the series of 1355 cases from the records of the Hospital for 
Ruptured and Crippled, the attempt was made to locate the origin 
of the disease by the most prominent spinous process in the trac- 
ing. The following are the conclusions : 

1 Transactions American Orthopedic Association, 1896, vol. ix. 

2 Ibid., 1891, vol. iv. 



24 



ollTUttVEDIC SURGERY. 



Flat . 
Beoond 

Third 
Fourth 
Fifth 
Sixth 

Seventh 
Eighth 

Ninth 
Tenth 

Eleventh 
Twelfth 



Cervical. 


Dorsal. 


Lumbar. 


Lumbosacral 


3 


26 


94 


13 


8 


43 


96 




15 


.42 


64 




20 


46 


57 




13 


49 


6 




22 


76 






24 


82 
97 
92 

110 
71 

120 







100 



854 



317 



13 

No deformity, cervical 2 

dorsal 31 

lumbar 22 



Disease in two regions of the spine 



Similar statistics are recorded by Julius Dollinger, 1 of Buda- 
pest, of TOO cases of Pott's disease. Of these the situation of 
the primary disease could be ascertained in 538. Of this number, 
in 63 the disease was of the cervical, in 321 of the dorsal, and in 
154 of the lumbar region. 

The relative frequency of disease of the different dorsal and 
Lumbar vertebrae was as follows : 





Dorsal. 


Luml 


First 


6 


59 


Second 


7 


37 


Third 


12 


31 


Fourth 


10 


17 


Fifth 


19 


10 


Sixth 


17 




Seventh 


33 




Eighth 


36 




Ninth 


36 




Tenth 


43 




Eleventh 


38 




Twelfth 


64 





321 154 

The proportionate length of the different sections of the spine 
at the age of five years is, according to Professor Disse (Skele- 
tal, iv, L89 

• :rnl 20.2 

Dona] 45.6 

Lumbar 34.2 

100.0 

If tlii- be contrasted with the percentage of the cases of disease 
of each section, it will show thai the frequency of the disease in 



Hang der Tuberculosen Wirbelentziindung. Stuttgart, 1898. 



TUBERCULOUS DISEASE OF THE SPINE. 25 

the different regions of the spine does not correspond to the area, 
as has been suggested, but that it is proportionately much less fre- 
quent in the cervical and ninch more frequent in the dorsal region. 

Dollinger. Frank and Giuiia-. 

Cervical . . . 11.7 per cent. Cervical . . .7.6 per cent. 

Dorsal . . . 59.6 " Dorsal . . . 61.1 

Lumbar . . . 28.6 " Lumbar . . . 26.2 " 

This may be explained apparently by the greater strain to which 
the middle and lower part of the spine is subjected, as well as by 
the relative proportion of cancellous tissue which offers the oppor- 
tunity for infection. 

Prognosis. The prognosis in tuberculous disease is discussed 
in Chapter V. Pott's disease is the most dangerous of all the 
tuberculous affections of the bones or joints, as would be expected 
from the relative importance of the structure affected and of the 
parts lying in contact with it. 

It is evident also that the amount of deformity and its situation 
have a direct influence on the prognosis. In disease of either 
extremity of the spine the direct deformity is insignificant and the 
secondary effect upon the trunk is slight. 

In the typical ' ' hump-back " deformity, however, the contents 
of the thorax and abdomen are necessarily compressed ; the blood- 
vessels are distorted, and the calibre of the aorta, which is more 
directly affected, is often much diminished; respiration is made 
difficult, and the circulation is impeded; as a consequence, the 
heart is usually hypertrophied and valvular insufficiency is not 
infrequent. Thus the vital functions, which are carried on at a 
disadvantage even under favorable conditions, become impossible 
under the added strain of unfavorable surroundings, overwork, 
or disease. It is a matter of common observation that few of 
those who are markedly deformed reach old age. On the other 
hand, it may be assumed that slight deformities, or those which 
do not as directly interfere with the vital functions, exercise but 
little influence upon the future well-being of the patient. 

Although the absolute mortality of Pott's disease cannot be 
accurately estimated, it may be stated that at least 20 per cent, 
of all patients die during the progress of the disease and within a 
few years after it- onset, from causes directly or indirectly 
dependent apou the local lesion. Some of these die from general 
dissemination of the tuberculous infection and tuberculous menin- 
gitis; some from exhaustion following septic infection and long- 
continued suppuration, or from amyloid degeneration of the 



26 ORTHOPEDIC SURGERY. 

internal organs; Borne from tuberculosis of the lungs, and many 
from intercurrent affections that arc fatal because of the devital- 
izing Influence of the disease and its complications. 

Hie prognosis of Pott's disease in the individual case is influ- 
enced by many considerations. In one instance the family history 
is good, the surroundings are favorable, the patient is in good 
condition, and the disease is in the early stage; one is then inclined 
to Look upon it as an accident, and hardly considers the possibility 
of a fatal termination; while in another case the weakness and 
ondervitalization of the body are so evident that the affection of 
the spine seems but an incident of a general degeneration. 

Symptoms. The most distinctive sign of Pott's disease is 
deformity. At an early stage of the process there may be but a 
slight irregularity in the contour of the spine, and if several adja- 
cent vertebral bodies are affected the projection may be somewhat 
rounded in outline; but as compared with other deformities of 
the spine, that of Pott's disease is characteristically angular, and 
as it- cause is loss of substance, its formation is accompanied by 
and must have been preceded by the symptoms of bone disease. 

Deformity is thus the evidence of a destructive process that 
may have existed for weeks or months even, and only by its early 
recognition can the ideal result — the prevention of deformity — be 
attained. The spine which, although weak, is still straight may 
be held straight ; but when the deformity is present, it can be 
remedied only in part, and it may be difficult even to check its 
further progress. For as the upper segment of the spine sinks 
forward and downward, the influences of compression and attrition 
increase the activity of the local process and aggravate its effects. 

For many years angular deformity was thought to be the essen- 
tial sign of Pott's disease, and even now the fact is not generally 
recognized that the detection of tuberculous ostitis of the spine in 
the early stage is both possible and easy, if one will apply the 
same methods that serve for the diagnosis of other affections not 
attended by such obvious symptoms as external deformity. It is 
t<» such application of the principles of differential diagnosis that 
attention i- especially called. 

The -pine i- the chief support of the body, possessing a free 
mobility that accommodates it to every movement of the trunk 
ami to every motion of the limbs even. It is evident, therefore, 
that the symptoms «»f a destructive disease must be pain, weakness, 
and impairment of normal motion. Motion and support are not, 
however, the only functions of the spine; it contains the spinal 



TUBERCULOUS DISEASE OF THE SPIXE. 27 

cord, from which branch the nerves that supply the organs and 
members of the body. This may be implicated at an early stage 
of the affection and the sudden onset of paralysis may overshadow 
the symptoms of the original disease. In other instances the tumor 
of an abscess — one of the common accompaniments of tuberculous 
disease of bone — may interfere with the functions of important 
parts lying in the neighborhood of the spine, and peculiar symp- 
toms, due to this cause, may attract attention before the primary 
disease is suspected. Such symptoms may be misleading and it 
is well, therefore, to consider them apart . from those that indicate 
the primary effect of the disease upon the spine, considered as an 
elastic support. These direct symptoms usually precede and 
always accompany the secondary or complicating symptoms, and 
upon them the diagnosis depends. 

The primary and diagnostic symptoms of Pott's disease may be 
classified as follows : 

(a) Pain. 

(6) Stiffness. 

(c) Weakness. 

(d) Awkwardness. 

(e) Deformity. 

(«) Pain. At first thought, one might expect the pain of Pott's 
disease to be localized at the affected vertebra?, and to be accom- 
panied by sensitiveness to pressure or even by infiltration and 
swelling of the tissues ; but it will be remembered that the bodies 
of the vertebrae are in the interior of the trunk, practically speak- 
ing, as near to its anterior as to its posterior surface (Fig. 9), and 
that the products of the disease pass downward and forward, 
rarely backward. Thus sensitiveness to pressure on the projecting 
spinous processes is unusual, and palpation, except in the cervical 
region, is of comparatively little diagnostic value. 

The pain of Pott's disease is not localized in the back, in the 
neighborhood of the disease, because the filaments that supply 
the bodies of the vertebrae are insignificant parts of nerves that 
are distributed to distant points — to the head, to the limbs, to the 
front and sides of the trunk — and to these parts the pain is re- 
ferred; thus " earache" or " stomach-ache " or " sciatica " may 
be symptomatic of Pott's disease. The pain of Pott's disease is 
by no mean- constant; it is induced by jars or by sudden or 
unguarded movements. It i- often worse at night, when, after 
the relaxation of the muscular spasm thai has protected the part, 
the unconscious movements during sleep cause discomforl or pain, 



2S 



ORTHOPEDIC SURGERY. 



and die child moans in its sleep, or is restless, and sometimes it 
wakes with a cry — " night cry." 

( I) ) Impairment of Function or Loss of Normal Mobility : Stiffness. 
Stiffness of the spine is in part voluntary, in the sense that the 
patient adapts his movements and attitudes to the disease and pain 
— in order to avoid as far as possible strain and jar — but the 
essential and characteristic stiffness of Pott's disease is caused 
by the involuntary muscular tension and contraction of the muscles 
about the seat of disease. This reflex muscular spasm varies in 
degree, according to the state of the underlying disease. It may 
fix the spine or it may be evident only at the extremes of motion, 
but it is always present, preceding deformity and accompanying 
it until cure is established ; thus it is the 
most important of the diagnostic symptoms 
of Pott's disease. 

(c) Weakness. As the disease affects the 
most important support of the body, it is 
a direct as well as an indirect cause of weak- 
ness, and the more vulnerable the spine, 
the more pronounced is this symptom ; thus 
in a young child, whose spine is in great 
part cartilaginous, evidence of weakness is 
shown by the " loss of walk," the refusal to 
stand, and by the instinctive desire for 
support, at an early stage of the disease. 

(d) Change in Attitude : "Awkwardness." 
This really sums up the effects of the pre- 
ceding symptoms, since it is evident that 
pain, weakness, and rigidity must cause a 
change in the appearance and in the habit- 
ual attitudes of the patient. Such symp- 
tomatic attitudes may be almost diagnostic 
of the disease and of the part of the spine 
involved. 

(e) Change in the Contour of the Spine : 
Deformity. The deformities of Pott's dis- 
ease may be classified as follows : 




A, direct deformity ; B, mm- 
<>ry deformity. The 
i line Indicates the' nor- 
mal contour of the spine. 



1 . Bone deformity. 

2. Muscular deformity. 



3. Compensatory deformity. 
The characteristic angular projection due to destruction of bone 
ha- heen described already. 



T UBEB CULOUS DISEA SE OF THE SPIXE. 2 9 

Muscular deformity is the distortion due to muscular spasm or 
contraction. Of this, the wry nock, symptomatic of cervical dis- 
ease, and psoas contraction in the lower region of the spine, arc 
the most familiar examples. 

Compensatory deformity signifies the more general effect of the 
local disease and local distortion upon the spine as a whole (Fig. 5). 
Thus an angular projection must be balanced by a compensatory 
incurvation, and lateral distortion in one direction by lateral dis- 
tortion in another. 

These three deformities are, of course, nearly related, and they 
are usually combined, although muscular distortion may precede 

Fig. 6. 




Normal contour and flexibility ot the spine. 

the stage of bone destruction, while the compensatory changes arc 
not immediately apparent. On the other hand, the secondary 
changes in the coutour of the spine may catch the eye before the 
primary local deformity is detected. 

Lateral deviation of the spine is not infrequent; it may be a 
direct distortion at the seat of the disease, caused by the destruc- 
tion of the side of a vertebral body (Fig. 22), but more often it is 
a secondary effect of such irregular erosion at one or the other 
extremity of the spine, or the effect <>f muscular contraction, or 
it may be due to simple weakness, in which case it i- ;i transienl 
symptom. 

Finally, even at the earliest stage of the disease, there Is almosl 
always a slight change in the outline of the spine due to local 



30 



ORTHOPEDIC srildERY. 



rigidity ; the spine qo longer forms a long, regular curve when the 
body is bent forward, bul as one section remains more or less 
rigid while the other bends, the outline is broken at or near the 
3ea1 of the disease ( Fig. 7). 

Secondary or Complicating Symptoms, (a) Abscess. This 
may, by its size or situation, cause peculiar symptoms. In the 
retropharyngeal space it may interfere with respiration and 
deglutition. In the thoracic region it might be mistaken for 



Fig. 7. 




Incipient Pott's disease. Showing the break in the contour of the spine, of which the 
normal flexibility is but slightly impaired. 



pleurisy or empyema, and when it forms a tumor in the iliac fossa 
it may interfere with locomotion. 

(7,) Paralysis. This is usually a late symptom, but if the disease 
begins in the centre or posterior part of a vertebral body it may 
implicate the spinal cord before deformity is apparent. 

Abscess and paralysis are symptoms that may be explained by 
Pott's disease, bul other than by calling attention to disease of the 
-pine as a possible cause of the complication, they do not aid one 



TUB EEC UL US DISEA SE OF THE SPIXE. 3 1 

in determining the diagnosis ; for this reason they are classed as 
secondary symptoms. 

General Symptoms. Especial stress is laid by certain writers 
upon the diagnostic value of a slight but constant elevation of the 
temperature. This is usually present if the disease is active or 
when an abscess is approaching the surface, but the positive value 
of the symptom in early or quiescent cases is doubtful. One may 
expect also that a patient suffering from tuberculous disease of the 
spine will present some evidence of a painful and depressing 
affection, or some evidence of inherited or acquired weakness ; yet 
it must be remembered that the absence of such general symptoms 
would not exclude Pott's disease. 

The Contour and Flexibility of the Normal Spine. In the enum- 
eration of the early symptoms of Pott's disease, two have been 
noted as of especial importance — the impairment of normal 
mobility and the effect of the disease upon the contour of the spine 
and upon the attitudes of the patient. Therefore, in the study of 
the normal spine the standard with which that suspected of disease 
must be compared — mobility and contour — at different ages and 
under different conditions should receive especial consideration. 

The spine as a whole is a flexible column, yet it has a fixed 
contour; it curves forward in the upper, backward in the middle, 
and forward again in the lower region. These curves are essen- 
tially the effect of the force of gravity and of the action of the 
muscles in balancing the weight of the body in the upright atti- 
tude. In the adult they are practically constant; in early child- 
hood they can be nearly obliterated by traction in the horizontal 
position ; and in infancy they do not exist. If the newborn infant 
be placed in the sitting posture, the head falls forward and the 
-pine bends in one long, backward curve, characteristic of weak- 
ness. If it be placed on the back and the legs be drawn down 
from their habitual attitude of semiflexion, it will be noticed 
that the range of extension is somewhat limited because of the ab- 
sence of the lumbar curve and the inclination of the pelvis. When 
the gain in muscular power is sufficient to enable the infant t<» 
raise and control the head, the curve of the neck appears. Later 
when the child stands, the erector spinae muscles hold the body 
upright against the resistance of the iliopsoas group and of the 
ligaments of the hip-joint; thus the Lumbar curve and the inclina- 
tion of the pelvis result and the normal contour <>f the -pine ie 
established. 

If from the odontoid process of the axis of a normal individual 



32 



nliTHOPEDIC SURGERY. 



Fig. S. 



in the erect posture a line he dropped to the ground, this perpen- 
dicular or weight line, about which the weight of the body is 
balanced, will indicate the curve of the spine, and divide it into 
sections that correspond sufficiently well to function. The cervical 

curve ends at the second dorsal, the 
thoracic curve at the twelfth dorsal, and 
the lumbar curve at the sacrovertebral 
angle (Fig. 8). 

What has been spoken of as the 
normal contour of the spine varies con- 
siderably in the adult. It is affected 
by the occupation and many other cir- 
cumstances ; of this, the round shoulders 
of the cobbler or the weaver, the stoop 
of weakness, of old age and the like, are 
familiar examples; but in childhood dis- 
tinct variations from the normal contour 
almost always have a clearly denned 
pathological cause. As the normal con- 
tour is the effect of the balancing of the 
body in the upright posture, it is evi- 
dent that if the outline of one part is per- 
manently changed, compensation for this 
change must be made in another part. 
Thus when deformity is well marked, 
the normal curves of the spine are often 
completely reversed (Fig. 5), and even at an early stage of the 
disease the abnormal contour will often attract attention, long 
before the characteristic angular projection has become apparent. 




The divisions of the spine. 



Divisions of the Spine. 

Although the spine is a flexible column whose outline changes 
with every movement and posture, yet the range and char- 
acter of this motion vary greatly in different parts. In the cer- 
vical and lumbar regions motion is extensive, because of the 
relatively large proportion of elastic intervertebral substance, 
because of the direction of the articular surfaces, and because 
the centre of motion is near the middle of the body. Motion is 
very limited in the thoracic region, because the intervertebral 
disks are thin, because of the overlapping spinous processes, and 
because it forms a part of the rigid thorax. Where free motion 
is essential to the habitual attitudes, interference with normal 



TUBERCULOUS DISEASE OF THE SPINE. 



33 



motion and the other attendant symptoms of disease will be 
apparent earliest. Thus one more often has the opportunity for 




***<*».. 



Xnflary^ lK 



phr* 






rywm 



v 



Cross-section of the body of a child at the third dorsal vertebra. (Dwight.) 

early diagnosis in disease of the lumbar and cervical regions, 
b eanse in the one the motions necessary in stooping, sitting, and 

3 



34 nimiOFEDIC SURGERY. 

standing arc constrained, and in the other the neck is stiff, or the 
head is turned, or drawn from the normal line. In the thoracic 
region early diagnosis is less often made, because in this section 
motion is SO unimportant that its restraint may escape the atten- 
tion of the patient or parent. In considering diagnosis, therefore, 
and, in fact, treatment and prognosis, one should divide the spine 
into three sections to cDrrespond with function : 

1. The neck part, that allows free motion of the head, ending 
at the third dorsal vertebra. 

2. The rigid thoracic part, which includes the third and the 
tenth dorsal vertebra. 

3. The lower part, made up of the two lower dorsal and the 
lumbar vertebrae, in which the principal movements of the trunk 
are carried out (Fig. 8). 

One must bear in mind the distribution of the nerves, because 
the characteristic pain is referred to their terminations, also the 
parts in relation to the spine at different levels that may be impli- 
cated in the disease. Thus, remembering that the symptoms 
of Pott's disease are in general, stiffness, weakness, pain and 
deformity, one will always apply these symptoms to a particular 
region of the spine, and will picture to himself the effect of such 
stiffness, weakness, and deformity at this or that vertebra ; the 
effect of an abscess in this or that situation, and the area of paral- 
ysis that might be caused by pressure on the cord at one or another 
level. 

Landmarks. The atlas is on a line with the hard palate. 

The axis is on a line with the free edge of the upper teeth. 

The transverse process of the atlas is just below and in front of 
the tip of the mastoid process. 

The hyoid bone is opposite the fourth cervical vertebra. 

The cricoid cartilage is on a line with the sixth cervical vertebra. 

The upper margin of the sternum is opposite the disk between 
the second and third dorsal vertebrae. 

The junction of the first and second sections of the sternum is 
opposite the fourth dorsal vertebra. 

The tip of the ensiform cartilage is opposite the lower part of 
the body of the tenth dorsal vertebra. 

The anterior extremity of the first rib is on a line with the fourth 
rib at the -pine, the second with the sixth, the fifth with the ninth, 
tin- seventh with the eleventh. 

The scapula overlaps the second and the seventh ribs, its lower 
angle being opposite the centre of the eighth dorsal vertebra.. 



TUBERCULOUS DISEASE OF THE SPINE. 35 

The root of the spine of the scapula, the glenoid cavity, and 
the interval between the second and third dorsal spines are in the 
same plane. 

The most constant landmark from which to count is the spinous 
process of the fourth lumbar vertebra, which is on a line with the 
highest point of the crest of the ilium. The umbilicus is near the 
same plane. 

The Inclination of the Pelvis. In the erect attitude the plane of 
the brim forms an angle of 60° to 6o° with the horizon. 

The tip of the coccyx is opposite the lower border of the sym- 
physis pubis. 

Length of the Spinal Cord. In the adult the spinal cord termi- 
nates at the lower margin of the first lumbar vertebra. At birth 
it extends to the third lumbar vertebra and its membranes to the 
second division of the sacrum. 

The Intervertebral Disks. In the adult the intervertebral disks 
form 41.9 per cent, of the cervical, 26.4 per cent, of the dorsal, 
and 44.6 per cent, of the lumbar regions of the spine (Dwight). 

The character of the disease, its manifestations, and its effects 
upon the spine having been outlined, the student is now brought, 
as it were, into actual contact with the patient and his friends. 
And as Pott's disease is the most important of the chronic affec- 
tions of childhood, it will serve as a type to illustrate methods of 
examination and of treatment as applied in orthopedic practice. 

The Rational Signs. The symptoms of Pott's disease vary 
decidedly, not only with the region of the spine involved, but also 
with the age and surroundings of the patient. Like other forms 
of tuberculous disease it is an insidious chronic affection, and its 
early symptoms may fail to attract attention, because they are 
irregular or intermittent. The child may cry after overexertion 
or injury, but otherwise it may appear to be perfectly well for 
weeks or months even. When the diagnosis is evident, however, 
the mother almost always recalls the fact that something was 
" wrong," that it was fretful and disinclined to play, that it liked 
to lie on the floor, that it was awkward in its movements, that it 
was troubled by a cough or indigestion, or by oppression of breath- 
ing. One, or many, of such symptoms may have existed for 
months; but, as a rule, it is not until deformity appears thai the 
child is brought for treatment. It is often after ;i fall or violent 
play that the evidence of pain or weakness can do Longer !><■ over- 
looked, so that injury is likely to occupy a prominent place in tli<' 
history. 



36 ORTHOPEDIC SURGEB Y. 

History. The history of the disease as obtained from the parent 
is usually indefinite and misleading. Certain points, however, of 
relative importance may be ascertained by an examination some- 
what as follows : 

One asks if the immediate relatives of the child have suffered 
from phthisis or other form of tuberculosis, as this might indicate 
a predisposition to disease, and thus affect the prognosis. 

One asks if the child has been robust or the reverse, and if 
recovery from the ordinary ailments of childhood was prompt 
or tedious, in order that one may judge of the quality of the 
patient. 

One next asks, not " how long has the child been ill?" for this 
is usually understood to refer to the duration of the more decided 
symptoms; but "when was the child last perfectly well?" One 
asks particularly as to the onset of the first symptoms, whether it 
was sharp and decided, or gradual and ill-defined; if the symp- 
toms were preceded by contagious disease. This latter is an 
important question, because measles, for example, predisposes to 
tuberculous infection, or at least to its local outbreak, and diph- 
theria is often followed by paralysis or by weakness that may 
simulate certain symptoms of Pott's disease. The character of 
the injury that almost every patient is supposed to have received 
is then investigated. It should be made clear whether the injury 
was the direct cause of the symptoms, or if it may have simply 
aggravated or brought to light the dormant disease, or if, as is 
often the case, there is simply an indefinite remembrance of an 
injury which has no connection with the symptoms. 

To establish injury as the sole and direct cause of symptoms, 
the patient must have been well at the time of the accident, the 
symptoms must have followed immediately and must have persisted 
since; and, finally, the symptoms must be of a nature to be ex- 
plained by a definite injury. 

By careful questioning one may usually determine whether the 
symptoms of which the patient complains are acute or chronic. 
This is of importance, because tuberculosis is a chronic disease — one 
of the few chronic diseases of childhood — although its exacerba- 
tions may resemble the symptoms of acute disease or even injury. 

However important a correct history may be, it is upon the 
physical examination that the diagnosis practically depends. 

Physical Signs. The physical examination begins on the first 
Bighl of the patient, for one may note then the general condition 
and the actions and postures; but the ultimate purpose of the 



TUBERCULOUS DISEASE OF THE SPINE. 37 

examiner is to compare the appearance and the mobility of the 
spine suspected of disease with the normal standard. 

Voluntary actions and attitudes are important, because they 
show the adaptation of the body to the disease, the conscious and 
unconscious efforts of the patient to guard the weak part from 
strain and from motions that cause discomfort and pain. Inspec- 
tion, palpation, and the tests of voluntary and passiye motion are 
of still greater importance, because by such means one may demon- 
strate the presence of disease and localize it with accuracy. 

The examination must be purposeful. When one asks the 
patient to pick up a coin from the floor, it is to test the lower 
region of the spine for the symptoms of weakness and stiffness. 
The ability to perforin the act with ease by no means excludes 
disease of the spine in the regions not especially involved in the 
movements of stooping or turning the body, although this would 
appear to be the general belief. 

Such tests must not only be purposeful, but they must be 
adapted to the age and intelligence of the patient. The child that 
refuses to pick up a coin will often gather up its clothing, because 
it wishes to be dressed again. If it will not stoop, it will rise 
usually if placed in the recumbent or sitting posture — an equally 
useful test. A child will walk toward its mother if placed at a 
distance from her. It will always turn its head toward her ; thus 
voluntary motion of the cervical region may be tested by changing 
the mother's position, while the child is held by the examiner. 
Young children that struggle and resist passive motion if placed 
on the table, submit quietly when held in the mother's arms. 

Various simple and effective tests will suggest themselves to 
the examiner who has a definite purpose in view, but much patience 
may be required in early cases, and several examinations may be 
necessary before the presence or absence of disease can be definitely 
determined. It is important to remember that, in childhood al 
least, abnormal symptoms always have a cause; therefore, a patient 
should be kept under observation until the cause is discovered. 

Of all the early signs of Pott's disease muscular rigidity or reflex 
muscular spasm is the most important, since it precedes deformity 
and accompanies it until cure is finally established. It is a spasm 
that resists motion in all directions; thus it may Ik; distinguished 
from the spasm or contraction of certain groups '>f muscles caused 
by irritation or inflammation not connected with the spine. For 
in such instances motion i- limited only in the directions directly 
opposed by the muscular contraction. True reflex muscular -]>:!-m 



;>S ORTHOPEDIC SURGERY. 

is quite independent of the will, and thus it may be distinguished 
from simple voluntary resistance on the part of the patient. 

The muscular rigidity is most marked in the neighborhood of 
the disease, but it extends to a greater or less distance according to 
theacutenesa of the local process and the susceptibility of the patient. 

Even at an early stage the situation of the disease is usually 
shown by a slight irregularity of the spine in the centre of the 
area made rigid by muscular spasm, as well as by the change of 
contour. This change in outline and in flexibility may be demon- 
strated by bending the patient forward. If the spine forms a long, 
even, regular curve, and if there is no evidence of pain or rigidity 
when such an attitude is assumed, Pott's disease is extremely 
improbable. If, on the other hand, the outline of the curve is 
broken ; if the motion of one section of the spine is restrained by 
muscular rigidity, disease may be suspected ; and if other evidence 
of tuberculous ostitis is present, the diagnosis may be made with 
certainty (Figs. 6 and 7). 

By a careful physical examination one may expect to detect 
Pott's disease at its inception and to fix upon its location, or at 
least upon the point suspected of disease. One will then ask 
one's self if tuberculous disease of the bodies of the vertebrae of this 
particular region will satisfactorily explain all the symptoms of 
which the patient complains ; if, for example, the pain corresponds 
to the distribution of the nerves ; if restraint of function will 
explain the attitudes of the patient, and if the change in contour 
is significant of a destructive process. 

As has been stated, the symptoms and the effects of the disease 
differ according to the function of the part of the spine involved ; 
the further examination should be conducted, therefore, from 
this standpoint. 

The Regional Examination. 

1. The Lower Region. Considering the regions of the spine 
in the order of liability to disease, one begins with the lower sec- 
tion, comprising the lumbar and the two lower dorsal vertebrae, 
that more nearly correspond in shape and function to the lumbar 
than to the thoracic division. 

This is the region of constant and extensive motion; thus the 
painful rigidity, characteristic of the disease, is often marked 
Long before the stage of bone destruction. 

The characteristic attitude of the patient is one of what might 
be called overerectnes6, and in many instances there is an in- 



TUBERCULOUS DISEASE OF THE SPIXE. 



39 



creased hollowness (lordosis) of the back (Figs. 10 and 12); thus 
the prominent abdomen may first attract attention. The walk is 
careful, and a peculiar tip-toeing step, the feet being slightly 
inverted to avoid the jar of striking the heels, is often observed; 
this is, however, not a peculiarity of disease of this region alone, 
but is rather an evidence that the spine is sensitive to slight jars. 
More characteristic of lumbar disease is a peculiar swagger or 



Ftg. 10. 



Fig. 11. 





Disease of the upper lumbar region before 
the stage of deformity, showing abnormal 

lordosis. 



The same patient (Fig. 10) five years 
later, showing deformity. 



waddle, explained in part by the exaggerated lordosis, and in 
part by the loss of the accommodative, balancing motion of the 
lumbar spine, as the weight falls alternately on each limb in 
walking. 

The increased lumbar lordosis, so characteristic of the early 
stage of the disease, Is capable of several explanations. It is 
partly voluntary ; as bending the body forward brings pr< 



40 ORTHOPEDIC STJRGEH V. 

upon the diseased vertebral body, so bending it backward relieves 
this pressure. It is partly involuntary, caused by the contrac- 
tion of the large muscular masses on the posterior aspect of the 
spine ; and it is in part compensatory, as the slight psoas con- 
traction which is often present has a tendency to tilt the pelvis 
forward, necessitating a greater compensatory backward inclina- 
tion of the body. 

As the disease progresses the lumbar section becomes straighter, 
and finally it may project backward in the characteristic angular 
deformity. Yet even after the lordosis has been obliterated the 
backward inclination of the body still continues as a compensation 
for the change in balance, Avhich the transformation of the for- 
ward curve to a posterior deformity has necessitated (Fig. 11). 
Thus overerectness or backward inclination of the body charac- 
terizes the disease of this region from its beginning to its end in 
uncomplicated cases. 

Slight psoas contraction as a part of the general muscular spasm 
about the diseased area simply increases the lordosis ; but if the 
contraction is greater, when for example an abscess is present 
which involves the substance of the psoas muscles or forms a 
painful tumor in the pelvis, the erect attitude is no longer possible. 
The thighs are drawn toward the body, and the body is inclined 
forward to relax the tension. As this greater contraction, with the 
abscess that is usually its cause, is commonly unilateral the patient 
" favors " the flexed limb, and the resulting limp is often mis- 
taken for a sign of hip disease. Unilateral psoas contraction is, 
in fact, so often present when the patient is first brought for treat- 
ment, that a limp and the accompanying inclination of the body 
may be considered as characteristic of disease of the lumbar region 
at a somewhat advanced stage (Fig. 13). 

The location of the pain depends upon the distribution of the 
nerves that supply the diseased vertebra? or that pass in their 
vicinity ; it may radiate over the inguinal region or backward to 
the loins or buttocks or down the front or back of the thighs to 
the knees. Painful "cramp" is sometimes a prominent symp- 
tom ; the limb is spasmodically drawn toward the body and the 
patient, seizing it with both hands, shrieks with pain. 

Lateral inclination of the body is often present. It is usually a 
symptom of unilateral psoas contraction and abscess; it may be 
due also to unilateral contraction of the muscles of the back, or 
at a later stage it may indicate collapse or destruction of one side 
of a vertebral body. In other instances it is not a fixed attitude, 



TUBEBCULOUS DISEASE OF THE SPIXE. 



41 



but is simply a voluntary adaptation to weakness or pain ; thus 
one may find a large abscess in one pelvic fossa unaccompanied 
by psoas contraction, while the body is inclined toward the 
opposite side, apparently because the weight is supported habitu- 
ally on this limb. 



Fig. 12. 



Fro. 13. 





Disease of the lumbar region. First 
symptom, pain in the knees. 



Disease of lumbar region with right iliopsoas 
abscess and psoas contraction. 



The stiffness, weakness, and pain, characteristic of disease in 
this region are exemplified in many ways; for example, the child 
may be unable to turn in bed; it is slow and awkward in rising 
in the morning or in changing from an attitude of real to one ol 
activity. Jt often prefers to stand rather than to sit, becai 
the latter position more weight is thrown upon the sensitive 



42 



oirrnorEDic surgery. 



vertebra] bodies. When seated, particularly when riding in a 
carriage or street ear, the patient often sits upon the edge of the 
-t;it, the shoulders only touching the back, while the hands rest 
instinctively <»n the seat, partially supporting the weight and 
steadying the spine. 

Stooping) a posture that increases the pressure on the diseased 
vertebral bodies and which necessitates muscular tension and 

strain in regaining the erect posi- 
tion, is particularly difficult and 
it is always avoided by the 
patient if the disease is at all 
acute. For example, when the 
child is asked to pick up an ob- 
ject from the floor, it either re- 
fuses or it squats on the heels 
or drops upon the knees (Fig. 14) 
instead of flexing the spine as in 
health. Young children, having 
seized the object on the floor, re- 
gain the erect attitude by push- 
ing the body up by the pressure 
of the hands on the thighs. If 
the child is placed upon the floor 
it will, if possible, seize the moth- 
er's dress or will crawl to a chair 
or other object upon which the 
body may be drawn up by the 
arms, so that the discomfort 
caused by muscular contraction of the back muscles may be 
avoided. 

After the inspection and the observation of the motions and 
attitudes of the patient, the examination of the range of passive 
motion is made. The patient is placed at full length face downward 
on a table, and the range of extension and of lateral motion is 
tested by lifting the legs and swaying the body gently from side 
to side (Fig. 15). The spine is so flexible in childhood that 
rigidity even in the upper dorsal region may be demonstrated by 
this method, and in testing the lumbar region the thorax should 
be fixed by the hand of the examiner. While the patient remains 
in this attitude, one should test for psoas contraction. The 
pelvis i- pressed firmly against the table with one hand, while 
the lei:, held in the line of the body, is gently lifted by the other 




Lumbar disease. The manner of picking 
up an object. 



TUBERCULOUS DISEASE OF THE SPIXE. 



43 



(Fig. 16). As tested in this manner, the normal range of hyper- 
extension at the hip-joint should allow the knee to be lifted two 
or three inches from the table. Slight restriction of extension 



Fig. 15. 




Showing the rigidity of the spine before appearance of deformity, 
Fig. 16. 




Test for psoas contraction. 



of both thighs, indicating a Blight degree of psoas contraction, 
is very common in lumbar Pott's disease; but when the restric- 
tion is marked, and especially if it be unilateral, a deep al 



II 



ORTHOPEDIC SURGERY. 



may be suspected. Such unilateral psoas contraction may be 
demonstrated by placing the child on the back, allowing the limbs 
to hang over the edge of the table, when the unaffected thigh 
will drop below its fellow (Fig. 17). 

As a rule, flexion of the lumbar spine is much more restricted 
in the early stage of the disease than is extension; this rigidity 
may be demonstrated by placing the child on its hands and knees, 
and lifting it from the floor, when the body, instead of bending 
over the supporting hands, retains almost its original contour 
(Fig. 18). 

As has been stated, even at an early stage of the disease one 
may detect often a slight fulness about the spinous processes or 



Fin. 17. 







A method of demonstrating psoas contraction. 



a slight irregularity in their line, about which the muscular spasm 
is most marked; this indicates the exact seat of the disease. 
Deep pressure on the spinous processes at this point will often 
cause pain, and sometimes greater elasticity at the diseased area 
may be demonstrated. Except in the hands of an expert, it is, 
however, a test of comparatively little value; and again it may 
be mentioned that local pain and local sensitiveness to pressure 
mi the spinous processes are not characteristic signs of Pott's 
disease. 

Finally, one should examine for pelvic abxecss. This may be 
suspected when unilateral psoas contraction is present in marked 
degree, although psoas contraction may be present without abscess 



TUBERCULOUS DISEASE OF THE SPIXE. 



45 



and abscess may be unaccompanied by psoas contraction when 
the substance of the muscle is not involved. 

The typical psoas abscess, as pictured and described, is the 
fluctuating tumor that suddenly appears on the inner side of the 
thigh, although it may have been many months in descending to 
this position from its original site. Demonstrable abscess is 
present at some time in at least 50 per cent, of the cases of lumbar 
disease, and its detection is a matter of importance, since its sub- 



Fig. 18. 




Disease of the lumbar region before the stage of deformity. A test for rigidity 



sequent behavior will often materially influence the treatment. 
The child is placed on the side, the thigh is flexed, and the hand 
is pressed gently down into the loin and iliac fossa. Sometimes 
the examination will be made easier by extending the limb and 
thus bending the spine forward toward the hand. Often in this 
manner one can make out the peculiar, sausage-like thickening 
on one or the other side of the spine, or a larger, rounded tumor 
in the iliac fossa, the presence of which would not otherwise 
have been suspected. 



{<; ORTHOPEDIC SURGERY. 

Diagnosis. If a careful physical examination were made in 
all BU8picious eases, by one at all familiar with the ordinary 
symptoms of Pott's disease, the Held for differential diagnosis 
would be small indeed; but it would appear that sueh examina- 
tions are not made usually by the physician who is first consulted. 
One may learn, for example, that the child has been circumcised 
because of pain about the genitals, or because of weakness of the 
limbs, supposed to be due to " reflex irritation ;" or if the patient 
is an adult, that he has been treated for sciatica, rheumatism, or 
strain, long after the evidence of Pott's disease, even in the 
angular kyphosis, would have been apparent had the back been 
inspected. 

Pott's disease is most often mistaken for some one of the fol- 
lowing affections : 

Lumbago. This may simulate some of the symptoms of Pott's 
disease of this region, but it is an acute affection, of sudden onset, 
usually accompanied by local pain and sensitiveness of the muscles 
themselves. 

Strain of the Back. This is often accompanied by stiffness and 
pain on motion, but, like lumbago, its onset is sudden and its 
cause is known. The pain is usually localized at the point of 
injury; it is relieved by rest, and the restriction of motion is, in 
great degree, voluntary. In Pott's disease the pain is neuralgic; 
it is often worse at night and the rigidity is due to reflex spasm. 

Sciatica. The pain of sciatica is most often unilateral: it is 
usually confined to the distribution of this nerve, which is often 
sensitive to pressure throughout its course. The pain of Pott's 
disease, if it is referred to the limbs, is usually bilateral and the 
nerve trunks are not often sensitive to pressure. In sciatica, 
movements of the leg that cause tension on the nerve are often 
painful, while motion of the spine is free, or but slightly restricted, 
the reverse of the symptoms of Pott's disease. It is true that 
lateral deviation and even rigidity of the lumbar spine are some- 
times observed in cases of lumbosciatic neuralgia of long standing, 
but if the latter symptom is marked the diagnosis may be regarded 
as open to question. 

Sacro-iliac disease is far more likely to be mistaken for disease 
of the hip-joint than of the spine; the pain and sensitiveness are 
usually Localized about the seat of disease and the movements of 
the spine are aol restricted. 

Lumbago and sciatica and sacro-iliac disease are extremely 
uncommon in childhood, and if supposed strains or injuries of the 



TUBERCULOUS DISEASE OF THE SPINE. 47 

back cause persistent symptoms, the appropriate treatment would 
be similar to that of Pott's disease; that is to say, fixation and 
rest of the suspected part, until the cause of the symptoms is made 
clear. 

The attitude, characteristic of Pott's disease of this region, the 
hollow back and prominent abdomen, combined with the waddling 

Fig. 19. 




Disease of the lower dorsal region. The earliest indication of deformity. 

gait, may be simulated by bilateral congenital dislocation oj the hip, 
in which the pelvis is suspended at a poinl behind its Qorma] posi- 
tion ; but in this instance the gait and attitude have existed since 
the child began to walk, and the symptoms of bone disease are 
absent A similar attitude is sometimes the resull of weakness or 
paralysis of the muscles of the back, as, for example, in progi 



IS ORTHOPEDIC SURGER Y. 

muscular atrophy or pseudohypertrophic muscular paralysis. In 
this latter affection there is also a disinclination to stoop, and there 
may be rigidity of the back, symptoms that bear a superficial 
resemblance to Pott's disease" ; but as there are no other signs of 
disease of the spine, it may be readily excluded. 

When psoas contraction is present in lumbar Pott's disease, the 
resulting limp, that is often accompanied by pain in the limb, is 
almost invariably mistaken for a symptom of hip disease. 

Although flexion of the leg caused by psoas contraction is a 
common accompaniment of Pott's disease, it is not usually an early 
symptom ; thus the history will probably call attention to symp- 
toms referable to the spine, that have preceded it. Again, the 
Limp of Pott's disease is caused simply by flexion of the limb, 
a Limp that is. not, as in joint disease, accompanied by pain on 
functional use. When, therefore, in the physical examination the 
tension of the contracted iliopsoas muscle is relieved by flexing 
the thigh still further, the other movements of the hip, abduction, 
adduction, rotation, and flexion, are free and painless. Thus, hip 
disease, in which all motions are restrained in equal degree by mus- 
cular spasm, may be excluded readily, except, perhaps, in infancy. 

Hip Disease in Infancy. At this susceptible age there is almost 
always sympathetic spasm of the lumbar muscles in acute affections 
of the hip, and similar spasm of the hip muscles may be present 
in Pott's disease of the lower part of the spine. Several examina- 
tions may be necessary before the exact location of the disease can 
be determined, and in doubtful cases the application of a temporary 
support to the back and thigh, such as a spica-plaster bandage to 
relieve the sympathetic spasm, is a useful aid in diagnosis. 

It has been stated that extension of the thigh only is restrained 
by psoas contraction. It will be evident, however, that the pres- 
ence of a large and painful abscess in the pelvis or thigh would 
limit motion in other directions as well; but even in such cases 
at least one movement is unrestrained ; thus disease within the 
joint may be excluded. 

Secondary Hip Disease. In Pott's disease of long standing, 
complicated by abscess, in which the tissues about the joint are 
infiltrated or traversed by discharging sinuses, secondary infection 
of the hip-joint is not an unusual complication. In such cases, 
when the linil) i- distorted and when motion at the hip is limited 
by the infiltrated and contracted tissues, it is not easy to determine 
the presence or absence of joint disease. Doubtful cases of this 
class should be treated symptomatically. 



TUBERCULOUS DISEASE OF THE SPIXE. 49 

Pelvic Abscess. As abscess is such a common complication of 
Pott's disease, it will be necessary to consider abscesses of other 
origin, that may cause occasionally symptoms resembling some- 
what those of disease of the spine. Such are the perinephritic 
abscess, and, more rarely, that of appendicitis. They differ from 
the abscesses of Pott's disease in that they are, as a rule, acute in 
their onset and are accompanied by constitutional symptoms and 
by local pain and tenderness. In such cases the motions of the 
spine may be restrained, but the restraint is in great degree volun- 
tary, quite different from the rigidity due to disease of its sub- 
stance. It is true that the pelvic abscess of Pott's disease which 
has become infected may cause constitutional symptoms, but the 
history of the disability and discomfort that must have preceded 
the abscess, together with the probable presence of deformity, will 
make the diagnosis clear. Chronic abscess in the pelvis of other 
than spinal origin may be the result of disease of the pelvic bones, 
or of the sacro-iliac articulations, or of the hip-joint. It may be 
caused by the breaking down of lymphatic glands, or it may have 
its origin in inflammation about the uterine appendages, and cases 
of so-called idiopathic inflammation and suppuration of the ilio- 
psoas muscle have been described. In childhood, chronic abscesses 
in this locality are almost always tuberculous in character, and are 
caused by disease of bone, either of the spine or of the pelvis. 
Disease of the spine can be determined usually by the methods 
already indicated, but if the abscess is of other origin its exact 
cause can be decided in many instances only by an operative explo- 
ration. Abscesses of this character, of slow and apparently pain- 
less formation, may finally cause a swelling in the inguinal region 
or about the saphenous opening, that in the adult is not infre- 
quently mistaken for hernia. In practically all cases, however, 
the tumor of the abscess may be made out on palpation within the 
pelvis, and, although the contents of the external sac may be in 
part forced back into the larger reservoir, it- reduction i- very 
different in feeling from that of a true hernia. 

Peculiarities of Lumbar Pott's Disease in Infancy. 

Attention ha- been called repeatedly to the great importance of 
careful observation of the postures and movements of the patient, 
to the change in the contour of the spine, and particularly to the 

abnormal lordosis and peculiar attitude of overerectness in the 
early stage of lumbar di^-;i-<-. But tin- description "f attitudes of 

4 



50 OR TIIOPEDIC S UR GER Y. 

standing and walking, and of the contour of the spine, which 
is the result of the erect posture, does not apply to the infant in 
arms, nor need the spine be divided into contrasting sections for 
the purpose of differential diagnosis. In Pott's disease of infancy 
the muscular spasm is usually more intense and its extent is greater ; 
the child screams when it is moved or when the diapers are 
changed. Slight irregularity of the spinous processes indicating 
the position of the destructive process is often evident and abscess 
is not unusual. There is usually no difficulty in determining the 
presence of disease even in very early cases, but, as has been men- 
tioned, it is sometimes difficult to decide whether the lumbar spine 
or one of the hip-joints is involved. 

Pott's disease of infancy may be mistaken for acute rhachitis, or 
scurvy. The symptoms of such affections are, however, not 
limited to the spine, but involve to a greater or less degree the limbs 
and joints, indicating that the discomfort and pain are due to a 
general, not to a local disease. 

The Rhachitic Spine. The deformity of the spine, caused by 
rhachitis, is not infrequently mistaken for the kyphosis of Pott's 
disease. 

It has been stated that when in early infancy the child is placed 
in the sitting posture the spine bends in a long, posterior curve, 
indicative of the weakness normal at this age. Such a curvature 
is characteristic also of acquired weakness and particularly 
that caused by rhachitis in early childhood. During the subacute 
stage of general rhachitis the child that has never walked or that 
has " lost its walk " sits much of the time in its chair, or is car- 
ried about on the mother's arm. In this posture the spine is 
bent backward and a curvature of the lower thoracic and lumbar 
region is habitual. Soon a slight projection persists, even when 
the child is lying down; it usually increases in size and becomes 
more resistant if its exciting cause remains; thus, a somewhat 
rounded and rigid posterior curvature of the dorsolumbar portion 
of the spine is formed. 

The diagnosis from Pott's disease should be made without diffi- 
culty, because the evidences of general rhachitis are always present, 
and because the deformity is almost as much to be expected as would 
be distortions of the legs were the child walking. If the patient 
is placed in its habitual sitting posture it will be seen that the 
deformity is simply an exaggeration of a normal attitude. In this 
attitude the patient remains contentedly for an indefinite time, 
whereas if Pott's disease were present the child would lie on its 



TUBERCULOUS DISEASE OF THE SPINE. 51 

back or abdomen. The projection is rounded, not angular, and 
if the patient be placed in the prone posture the projection may be 
reduced, in great part, by raising the thighs while gentle pressure 
is exerted upon the kyphosis. Finally, although such extension 
and pressure may cause discomfort, there is complete absence of 
the muscular spasm characteristic of Pott's disease. 

It may be stated, then, that the rhachitic deformity is a rounded 
curvature of the lower part of the spine. Its cause is weakness 
and habitual posture. The rigidity depends upon the duration of 
the deformity. The pain, if the rhachitis be acute, is general and 
it is easily explained by the sensitive condition of the bones and 
joints. It is true that rhachitis and tuberculous disease of the 
spine may be combined, but in such rare instances the symptoms 
of the more serious local disease will make themselves evident as 
distinct from those of the general weakness. 

Recapitulation. The more characteristic symptoms of disease 
of the dorsolumbar region may be summed up as follows : 

Increased lordosis or overerectness and a prominent abdomen ; 
a cautious, constrained, or waddling gait; less often a lateral 
inclination of the body or a limp caused by psoas contraction. 

Stiffness of the spine, which makes bending or turning the body 
difficult. 

Pain, referred to the back, to the inguinal region, or to the 
thighs, and in more advanced cases the characteristic deformity. 

Diagnosis. The attitude may be simulated by congenital dis- 
location of the hips and by pseudohypertrophic muscular paralysis. 

The limp may be mistaken for that of hip disease. 

The pain and stiffness for sciatica, rheumatism, lumbago, or 
injury. 

The abscess is to be distinguished from those from other sources. 

In young infants the symptoms may be simulated by hip disease 
and by acute rhachitis or scurvy. 

Finally, the deformity of the subacute form of rhachitis is bo be 
distinguished from that symptomatic of bone destruction. 

Disease of Thoracic Region of the Spine. 

The normal motion of this section of the spine, which includes 
the third and tenth vertebrae, is, as compared with those above 
and below it. slight; thus, disease of this region may no1 interfere 
to a noticeable degree with the general function of the spine. 

A& this part of the column curves backward, the deformity, often 



52 ORTHOPEDIC SURGER Y. 

unattended by severe symptoms, is not infrequently mistaken for 
round shoulders (Fig. 20). It seems probable, also, because of 
the normal backward curve, and because of the leverage exerted by 
the weight of the head and arms, that deformity quickly follows 
disease. At all events, patients are not often seen before it is 
present, so that diagnosis is usually evident on inspection of the 
patient. 

The attitudes are not especially significant. If the lower part 
of the region is involved, and if the disease be at all acute, they 
are similar to those of disease of the lower region, viz., erectness, 
the peculiar, cautious, in-toeing step, and the disinclination to 
bend the body forward (Fig. 19). 

If, on the other hand, the upper part is affected, the attitude is 
often, particularly in young children, one of weakness ; there is a 
slight forward inclination of the body, the head being tilted back- 
ward or inclined toward one side, and a peculiar shrugging, 
squareness, and elevation of the shoulders is often noticeable 
(Fig. 21). In many instances the apparent elevation of the 
shoulders is in reality caused by the deformity, which shortens the 
neck and lowers the head (Fig. 23). 

In this connection it should be mentioned that one of the 
secondary effects of the disease, the so-called pigeon breast, is, 
not infrequently, noticed by the parent before the angular deform- 
ity of the spine. In the pigeon breast of Pott's disease the for- 
ward inclination of the spine causes a flattening of the upper part 
of the chest, while the sternum sinks downward and becomes 
prominent; thus, the anteroposterior diameter of the thorax is in- 
creased, and it is compressed from side to side, resembling very 
closely the deformity of rhachitis. As the pigeon breast of Pott's 
disease is always secondary to the spinal deformity, its cause, of 
course, becomes apparent on examining the back. 

Of the early symptoms of disease of the thoracic region, pain 
and labored or " grunting" respiration are the most characteristic. 
Pain referred to the abdomen and to the front and sides of the 
chest is usually an early and often a constant symptom; thus, 
persistent "stomach-ache" in a child should always lead to an 
examination of the spine. A u spasm of pain" is sometimes 
excited by lateral compression of the chest, as when the child is 
Lifted suddenly by the parent. 

Of much greater importance, however, is the labored or grunt- 
in g respiration, which, indeed, is almost pathognomonic of Pott's 
disease. This "grunting" is caused by the interference with 



TUBERCULOUS DISEASE OF THE SPIXE. 



53 



respiration, more particularly with the normal rhythmical move- 
ments of the ribs. The restraint is, in part, due to muscular spasm 
and deformity and in part to the voluntary effort of the patient. 
The inspiration is quick and shallow, in great degree diaphrag- 
matic, and expiration is accompanied by a sigh or grunt. This is 
caused apparently by a momentary closure of the larynx to resist 



Fig. 20. 



Fig. 21. 





Pott's disease of the middle dorsal region at 
an early stage, showing slight increase of the 
dorsal kyphosis, without noticeable change in 
the attitude. Contrast with Fig. 21. 



Disease of the upper dorsal region. 
Characteristic attitude. 



the escape of air and thus sadden motion of the chest walls. 
Grunting respiration is, of course, an evidence of the more acute 
type of disease, but even in mild cases in children it will be noticed 
when the patient i- fatigued or during play. 

An irritating, aimless cough is often a symptom of disease of the 



54 



ORTHOPEDIC SUlldKRY. 



Fig. 22. 



upper dorsal region, and spasmodic attacks resembling asthma are 
not uncommon. 

In most instances the characteristic angular kyphosis will appear 

OB examination, and in the exceptional cases in which deformity 

is absent, a slight change in con- 
tour will be apparent when the 
patient is bent forward. In place 
of the long, regular curve of the 
normal spine a point where two dis- 
tinct outlines unite will be observed 
— one of which may be curved, 
while the other is practically straight 
(Fig. 7). 

The presence of muscular spasm 
may be shown by sudden move- 
ment of the s$ine, and it may also 
be demonstrated in children by rais- 
ing the legs and swaying the body 
from side to side, as illustrated in 
the preceding section (Fig. 15). 
The change in the rhythm of res- 
piration has been mentioned already. 
Although the respiratory movement 
of the entire thorax is lessened in 
range, the restraint does not affect 
all the ribs equally; those that 
articulate with the diseased verte- 
bras are often nearly motionless, 
while the movement of those at a 
distance from the disease may ap- 
proach the normal. 

In tracing the neuralgic pain to 
its origin the sharp, downward in- 
clination of the ribs must be borne 

in mind; tints, the cause of pain in the " stomach" must be 

looked for between the shoulder blades. 

As in the lumbar region, slight lateral deviation of the spine is 

not uncommon, and it may be accompanied by a noticeable twist 

or rotation so that the ribs on one side project slightly backward 

(Fig. -2-2). 

In this region of the spine the spinal cord is more often involved 

than in disease of other sections ; thus, an awkward, stumbling gait 




Marked lateral deviation of the spine 
with rotation. Deformity at the eighth 
dorsal vertebra. 



TUBERCULOUS DISEASE OF THE SPINE. 



55 



and finally a 'Moss of walk" maybe the symptoms that first 
attract attention. The paralysis of Pott's disease and its differen- 
tial diagnosis are considered in more detail elsewhere. 

Abscess as a complication of disease of the thoracic region cannot 
be demonstrated by palpation unless it has found an outlet 
between the ribs, but percussion will often show an area of dulness 
or flatness, extending from the diseased vertebrae toward the lateral 
aspect of the chest. :^This is due in part, however, to tho'inflam- 

Frc 23. 




Double psoas contraction of an extreme degree and paralysis. The arms used as supports. 

oratory thickening of the tissues in the neighborhood. In rare 
instances the abscess may press directly upon the trachea or bronchi 
and cause spasmodic attacks of dyspnoea resembling asthma. 

Diagnosis. It is hardly necessary to mention the list of affec- 
tions that may cause pain in the chest or abdomen ; it is sufficient 
to state that such symptoms always require a physical examina- 
tion. The same statement applies to irregular respiration, to 
cough, and to so-called asthma. 



56 ORTHOPEDIC SURGER Y. 

Occasionally tuberculous disease of the dorsal spine in adoles- 
oence is practically painless, and the resulting deformity is rather 
rounded than angular, so that it may be mistaken for round 
shoulders. ' k Hound shoulders" is, however, as a rule, of long 
duration. The exciting cause or causes of postural deformity, in 
occupation or otherwise, are indicated often by the history. The 
rigidity is less marked than in Pott's disease, and neuralgic pain 
is absent. 

The situation and shape of the rhachitic kyphosis has been 
described. It should be evident that a more or less angular pro- 
jection in the upper part of the spine could not be rhachitic; and 
yet because of the absence of pain this diagnosis is made not infre- 
quently, and as a consequence the activity of the tuberculous dis- 
ease may be increased by massage and exercises. 

Lateral deviation of the spine as a symptom of disease hardly 
could be mistaken for the ordinary rotary -later at curvature, in 
which pain and muscular rigidity are absent. 

Acute affections within the chest, pleurisy, pneumonia, and 
empyema, are sometimes accompanied by lateral deviation of the 
spine, but the sudden onset and the constitutional and local 
symptoms that accompany such affections should make the cause 
of the deformity and pain evident. It is because these cases are 
sometimes sent to orthopedic clinics for braces that they seem 
worthy of mention. 

The abscesses in this region, as has been mentioned, cause 
usually dulness or flatness on percussion of the chest, and within 
this area friction sounds and rales may be heard. The tubercu- 
lous fluid may remain indefinitely in the posterior mediastinum 
and the area of flatness may extend beyond the axillary line, yet 
it may give rise to no symptoms. If the diagnosis of Pott's dis- 
ease had not been made or if the presence of the abscess had not 
been determined by the previous physical examination, it might 
be mistaken, during an acute exacerbation of the disease or 
constitutional disturbance from other cause, for pleurisy or empy- 
ema or even for phthisis. In all cases, therefore, a careful exami- 
nation of the chest should be made from time to time in order 
that the presence or absence of abscess may be recorded. 

Recapitulation. Pott's disease of this region is often insidious 
in its onset, causing no positive symptoms before the stage of 
deformity. 

Its most characteristic symptoms are pain referred to the front 
and sides of the body and the grunting respiration. 



TUBERCULOUS DISEASE OF THE SPINE. 



57 



If the disease is progressive, the characteristic symptoms of 
Pott's disease — weakness and rigidity — are present. The atti- 
tude, when the disease is in the lower thoracic region, resembles 
that of lumbar disease ; if the upper part is affected the head is 
tilted somewhat backward and the shoulders appear to be ele- 
vated. 

In differential diagnosis one will consider the significance of 
pain, cough, or embarrassed respiration, and the affections for 
which abscess or paralysis might be mistaken. Also, round 
shoulders, rhachitic deformity, and lateral deviation of the spine 
as distinguished from the kyphosis of Pott's disease. 

2. The Upper Region. The upper region of the spine, which 
includes the cervical and two of the dorsal vertebra?, corresponds 



Fig. 24. 




Cervical disease with abscess. Characteristic altitude. 

in freedom of movements and in its contour to the lumbar region. 
For the purpose of study it must be divided into two parts. Of 
these, the superior or occipito-axoid section is peculiar, in thai it 
contains no vertebral body or intervertebral cartilage, and in that 



58 OR THOPEDIC S URGER Y. 

the movements of the head are carried out in special joints and 
are controlled by special muscles. 

Disease at this point is especially dangerous, because displace- 
ment or fracture of the weakened vertebra? may cause sudden 
death by pressure on the vital centres. 

Occipito-axoid disease is uncommon, and it is relatively more 
frequent in adult life than in childhood. 

Symptoms. In a typical case the symptoms are neuralgic pain 
radiating over the back and sides of the head, following the dis- 
tribution of the auricular and occipital nerves. The neck is stiff 
and the head may be fixed in the median line, the chin being 
somewhat depressed, but it is more often tilted to one side, simu- 
lating the attitude of torticollis (Fig. 24). 

The attitude and appearance of the patient, when normal move- 
ment of the neck is restrained by a painful disease, is character- 
istic- the eyes follow one, or the body is turned, when the 
attention of the patient is attracted. The patient moves carefully, 
in order to avoid jar ; often the chin is instinctively supported by 
the hand, and a favorite attitude is one in which the patient sits 
with the elbows on a table, the hands supporting the head 
(Fig. 25). If the attempt is made to raise the chin, or to rotate 
the head, the patient seizes the hands of the examiner, and, it 
may be, screams in apprehension. There may be slight bulging 
and thickening of the tissues at the seat of disease. The affected 
vertebra? are usually sensitive to direct pressure, and not infre- 
quently deep fluctuation in the suboccipital triangle can be made 
out. 

The atlo-axoid junction lies just behind the posterior wall of 
the pharynx, on a line with the upper teeth. Here abscess often 
presents itself, occasionally early in the course of the disease, 
causing symptoms characteristic of obstruction, such as snoring, 
change in the quality of the voice, difficulty in swallowing, or 
spasmodic attacks of so-called croup. When abscess is present 
and when the disease is at all acute, the reclining posture some- 
times aggravates the symptoms, so that " getting the child to 
bed " is often a tedious and difficult task. 

In certain cases one can determine whether the disease is of 
the occipito-atloid or of the atlo-axoid articulation, but, as both 
joints are to a great extent controlled by the same muscles, this 
is often impossible. 

The uppermost joint, that between the atlas and occiput, per- 
mits the nodding movement of the head, or flexion and extension 



TUBERCULOUS DISEASE OF THE SPINE. 



59 



on the spine; while the atlo-axoid joint permits rotation of the 
atlas about the axis to the extent of about 30° in either direction. 
If the disease be in the upper joint the nodding movements will 
be more restricted than those of rotation, and vice versa. The 
motion of the cervical region is very free ; so that to make the 
test one must grasp the neck firmly in order to restrain motion 
except in the joint under examination. Because of this freedom 
of movement, restriction of motion of the upper articulations 
is often overlooked when the disease is of the subacute variety. 

Fig. 25. 




Cervical disease. A characteristic attitude. 

The Lower Cervical Region. The symptoms of disease of the 
lower cervical section, although similar in character, are often less 
marked than those of the upper region. The cervical spine 
becomes straighter, and often a slight backward project ion or 
thickening indicates the position of the disease. The bead is 
usually turned to one side by spasm of the lateral musclee in an 
attitude of wryneck (Fig. 26). The pain is referred to the Deck, 



00 



ORTHOPEDIC SURGERY. 



to the sternal region, or down the arras, following the distribution 
of the brachial plexus. 

In the more advanced cases one's attention may be attracted 
to the cervical region, because the neck seems short and because 
the head is tilted backward. The entire back shows a com- 
pensatory flattening, yet no deformity is apparent until the 
occiput is raised and drawn forward, when a shelf-like projection 
may be felt, at what appears to be the top of the spine, but which 
is really an angular deformity at the third or fourth vertebra. 

This emphasizes the importance of a careful observation of the 
contour of the spine, and the necessity of explaining to one's self 
every change from the normal that may be noticed. 

Fig. 26. 




Disease of the middle cervical region at an early stage. 

Disease at the cervieodorsal junction resembles in its symptoms 
that of the upper dorsal region. The head is usually tilted back- 
ward (Fig. 21) or it may be turned to one side. Disease at this 
point is often subacute in character, and paralysis from implica- 
tion of the spinal cord sometimes appears before deformity is 
apparent. Occasionally irregularity of the pupils is present. 

The spinous process of the seventh cervical or first dorsal ver- 
tebra is often prominent (vertebra prominens) in normal indi- 
viduals, and it may be mistaken for the deformity of disease, 
especially when pain about this point is a symptom, as in hys- 
terical or hyperaesthetic persons. If such projection is symp- 
tomatic of disease there is almost always a slight compensatory 






TUBERCULOUS DISEASE OF THE SPINE. Q\ 

flattening of the spine below the point and a certain degree of 
rigidity of the surrounding muscles. 

Diagnosis. As stiffness and distortion of the neck are the 
most prominent symptoms of disease of this region, one must con- 
sider first the forms of torticollis for which it might be mistaken. 
In typical torticollis, the distortion of the head is caused almost 
invariably by contraction of the muscles supplied by the spinal 
accessory nerve, the sternomastoid, and trapezius ; thus, the chin 
is slightly elevated and turned away from the contracted muscle. 

Congenital torticollis, which has existed from birth, is not 
accompanied by pain, and it could hardly be mistaken for a 
symptom of disease. 

Acute rheumatic torticollis, " stiff neck/' is sufficiently common 
to be familiar in its characteristics. It is of sudden onset, "in a 
single night;" the affected muscles are sensitive to pressure; the 
course of the affection is short, and it is of comparative insig- 
nificance. 

A more persistent form of acute torticollis, accompanied by 
muscular spasm and by local tenderness, sometimes accompanies 
enlarged or suppurating cervical glands ; it may follow " ear- 
ache," "tonsillitis," "sore-throat," or any form of irritation 
about the pharynx. This form of wryneck is not only very 
painful, but it may persist indefinitely, and permanent deformity 
may result. The onset is usually sudden ; the pain and tender- 
ness are local, and are confined, as a rule, to the contracted part. 
The sternomastoid and trapezius muscles are most often involved ; 
thus, the wryneck is typical. If the tension be relaxed by 
inclining the head toward the contracted muscles, motion of the 
spine itself will be found to be free and painless ; but if traction 
be made on the contracted muscles it causes discomfort, and it is 
usually resisted by the patient. 

In disease of the occipito-axoid region the distortion of the 
head is, by no means, typical of sternomastoid contraction ; it 
may be tilted up or down or laterally to an exaggerated degree. 
In other words, the wryneck of Pott's disease is an irregular 
distortion, because it is not dependent on the contraction of a par- 
ticular muscle or muscular group. " In torticollis the chin is 
turned away from the contracted muscle, while in Pott's d 
it is turned toward the contracted muscle." This is an axiomatic 
expression of the fact that the distortion of the head symptomatic 
of atlo-axoid disease depends, in great degree, upon the spasm 
of the small muscles that directly control these joints, the recti 



62 R TH OPE DIC S UB GER Y. 

and obliqui, and not directly upon the contraction of the sterno- 
mastoid muscle, as in the ordinary form of wryneck. Again, 
the emit raction, symptomatic of Pott's disease, of this or other 
regions, is the result of muscular spasm, a muscular spasm that 
prevents painful motion. If the head be grasped firmly by 
the hands and if gentle traction is made, the muscular spasm 
relaxes and the patient experiences a sensation of comfort. If 
similar traction is made upon the contracted muscles of acute wry- 
neck, the pain is increased and the patient protests. 

In disease of the middle cervical region, however, the distor- 
tion due to the reflex muscular spasm may resemble closely that 
of simple torticollis, particularly if the latter is caused by the 
irritation of inflamed or suppurating glands. For, in such cases, 
there is usually much sensitiveness to manipulation, with more 
or less general muscular spasm, and diagnosis may be impossible 
until apparatus has been applied to rest the part and to correct 
the deformity. 

As has been stated, the head may be tilted backward to com- 
pensate for deformity in the middle cervical region, and in some 
instances it may be drawn backward by spasm of the posterior 
muscles. Such a case might be mistaken for cervical opisthotonos, 
or posterior torticollis, which is sometimes seen in young infants 
suffering from exhausting diseases, basilar meningitis, and the 
like. In such conditions, however, the characteristic symptoms 
of Pott's disease are, of course, absent. 

The opposite attitude, viz., a forward droop of the head due to 
weakness of the trapezii muscles, is not uncommon as a sequence 
of diphtheria or other forms of contagious disease. This droop 
may be accompanied, also, by spasm of one of the sternomastoid 
muscles and by pain. In such cases the history of the preceding 
affection, the weakness or paralysis of other parts, as of the soft 
palate, the muscles of accommodation of the eyes and the like, 
together with the general bodily weakness that the patients often 
present, should make the diagnosis clear. 

////'//// to the upper segment of the spine, a sprain, contusion, 
or fracture, unless efficiently treated, may cause symptoms resem- 
bling very closely those of tuberculous disease; for example, 
pain, radiating over the back of the head, rigidity and deformity 
of the neck, and even infiltration and local tenderness about the 
injured part. Such cases, when seen several weeks or months 
after the accident, are puzzling, because one may be in doubt 
whether the symptoms were caused by a simple injury or whether 



TUBERCULOUS DISEASE OF THE SPIXE. 63 

tuberculous infection may have followed or preceded it. In such 
cases a positive diagnosis cannot be made until the effect of rest 
and protection has been observed — that is to say, suspicious cases 
should be treated as one would treat actual disease. If the case 
is simply one of injury recovery will be rapid and complete, 
while if disease be present the symptoms only will be relieved. 

The occipito-axoid articulation may be involved in acute 
articular rheumatism or in chronic rheumatoid arthritis. If the 
manifestations are general in character the diagnosis is, of course, 
easily made ; but occasionally the joints at the upper extremity of 
the spine may be the seat of what appears to be an infectious 
arthritis, in which the symptoms are of sudden onset and are 
sometimes combined with fever and constitutional disturbance, 
and in which no other joint is involved. The sudden onset and 
rapid recovery are the diagnostic points. 

Abscess in the cervical region is a secondary symptom, and 
although the change in the voice or the difficulty in breathing or 
swallowing may be the most noticeable symptoms, yet they are 
always accompanied by some of the characteristic signs of Pott's 
disease. 

Whenever the diagnosis of cervical disease is made one should 
examine the throat, and whenever a chronic retropharyngeal 
abscess is present one should look for the symptoms of Pott's 
disease. 

The diagnosis of the retropharyngeal abscess can be made only 
by inspection and palpation ; therefore, one need only mention 
the fact that symptoms of obstruction in the throat, similar to 
those of abscess, may be caused by adenoid growths and by 
enlarged tonsils. 

Retropharyngeal abscess is by no means always symptomatic 
of Pott's disease. It may be one of the sequelae of contagious 
disease or a complication of pharyngitis. It is then rapid in its 
onset and is not accompanied by the symptoms of Pott's disease. 

Recapitulation. If the disease is of the upper or occipito- 
axoid region the head is usually fixed in an attitude of deformity, 
which is sometimes slight and sometimes extreme. 

If the disease is of the middle region, the attitude more often 
resembles that of ordinary torticollis. In the lower region there 
is often no marked spasm of muscles, but the head inclines back- 
ward or toward one shoulder. 

The contour of the cervical spine changes as the dfc 
progresses; the normal anterior curvature is obliterated; thus, 



(J4 OR TH OPE DIC SURGER Y. 

the head is pushed forward, while the dorsal section of the spine 
becomes flat or even incurvated in compensation. The seat of the 
disease is often shown by an area of thickening or local tender- 
ness to deep pressure. 

Disease of the joints of the upper or occipito-axoid section is 
often acute in onset, in some instances apparently a form of 
synovial tuberculosis, and abscess is a very frequent complication. 

Differential diagnosis of disease in this region will include the 
consideration of the various forms of wryneck, cervical opisthot- 
onos, diphtheritic paralysis, and injury. Secondary abscess 
must be distinguished from simple retropharyngeal abscess and 
from other forms of obstruction in the throat. 

Diagnosis in General. Weakness and the so-called " loss of 
walk" are well-known symptoms of Pott's disease, and on this 
account children suffering from different forms of weakness or 
paralysis are often sent to orthopedic clinics for the treatment of 
" spine disease." 

Certain forms of paralysis bear a superficial resemblance to 
some of the symptoms of Pott's disease ; for example, pseudo- 
hypertrophic muscular paralysis to the attitude caused by disease 
of the lumbar region, and diphtheritic paralysis to that of the 
dorsal region. Spastic paralysis, of cerebral origin, resembles 
somewhat the paralysis of Pott's disease, but it may be differen- 
tiated by the absence of pain, by the history, and by what is 
apparent in most cases, the mental impairment. 

Primary spastic spinal paraplegia resembles the paralysis of 
Pott's disease more closely, but here, again, the essential symp- 
toms of a destructive disease of the spine are absent. 

The contractions combined with the weakness and pain that 
sometimes follow cerebrospinal meningitis may be mistaken for 
the symptoms of bone disease, but are, as a rule, readily explained 
by the history of the case. 

Forms of organic disease of the spine other than tuberculosis, 
as, for example, malignant disease, syphilis, spondylitis defor- 
mans aud the like, are described in Chapter II. 

The list of affections that has been considered in the differen- 
tial diagnosis is a long one, but it has been made up from actual 
experience. Most of the mistakes in diagnosis may be explained 
by carelessness or ignorance, or because of insufficient opportunity 
for examination j but in the earliest stages of the disease repeated 
examinations and even tentative treatment may be necessary 
before the diagnosis is confirmed. 



TUBERCULOUS DISEASE OF THE SPINE. 



Go 



The Roentgen Ray Photography as a Means of Diagnosis. The 
Roentgen ray is of comparatively little importance from the diag- 
nostic standpoint, but it may be of value as a means of determining 
the exact extent of the disease. If the negative is well denned, 
the diseased vertebra? are seen to be irregular in outline, or they 
may be lost in a peculiar blur. By counting from above and 
below the exact extent of the disease may be made oat, bat infer- 
ences as to its character and quality mast be made from the 
rational and physical signs (Fig. 34).' 

The Record of the Case. The history and the resalts of the 
examination of the patient should be recorded somewhat in the 
following order : 

1. The family and the personal history. 

2. The history of the disease, with especial reference to its 
mode of onset, its probable duration, to the noticeable symptoms, 
and to previous treatment. 



Fig. 27. 




Tracings of the spine illustrating the recession of deformity. 

3. The physical examination. This should include the general 
condition of the patient, the height and weight, the attitude, the 
character of the disease, whether progressive, as indicated by 
muscular spasm and pain on motion, or quiescent, the presence 
of abscess or paralysis as a complication, and, finally, the position 
and extent of the disease. This is best shown by a tracing, made 
by means of a strip of lead or pure tin, of such thickness that it 
may be readily moulded on the spine and yet hold its shape when 
removed (Fig. 27). 

The tracing should be of the entire spine, made while the 
patient lies extended in the prone position, and the exact Location 
of the most prominent spinous processes should be marked upon 
it. In determining the position of the disease it is well to counl 
the spinous processes from below upward, beginning with that 
of the fourth lumbar vertebra, which lies on a line drawn between 
the highest points of the iliac crests. There are other landmarks 

5 



66 ORTHOPEDIC SURGER Y. 

that are approximately correct. Sometimes the last rib may be 
traced to its origin ; the scapula covers the second and seventh 
ribs, the root of the spine of the scapula and the middle point of 
the glenoid cavity being on a line with the third, and its inferior 
angle opposite the tip of the seventh dorsal spinous process. The 
upper margin of the sternum is opposite the interval between 
the second and third dorsal vertebrae. In many instances the 
vertebra prominens and the spinous process of the axis can be 
identified. Such landmarks are, of course, somewhat displaced if 
the deformity is extreme, but they are always sufficiently correct 
to check errors in counting the spinous processes. 

The history furnishes a foundation on which treatment is con- 
ducted and from which its results may be determined. The 
study of final results has become of great importance in ortho- 
pedic surgery, and on this account the record should present the 
condition of the patient when treatment is begun, in a form that 
may be readily understood, not only by its writer when details 
have been forgotten, but by anyone who may in after years con- 
sult it. In this history the complications and incidents and the 
changes in the treatment should be noted at regular intervals 
until the patient is cured. 

Treatment. The general treatment of tuberculous disease is 
considered in Chapter V. Pott's disease is the most important 
of the tuberculous affections of the bones, and the importance of 
proper surroundings, proper food, sunlight, and above all open 
air both day and night, if possible, can hardly be exaggerated. 

The General Principles of Mechanical Treatment. Under normal 
conditions the weight of the head and of the thoracic and abdom- 
inal organs tends to bend the spine forward and downward — a 
tendency that is resisted by the action of the muscles of the back. 
If the resistance is weakened, as in Pott's disease by the direct 
destruction of the weight-bearing portion of the spine, this ten- 
dency toward deformity is, of course, greatly increased. Thus, 
the pressure of the superincumbent weight upon the weakened 
part and the strain of motion are, from the mechanical stand- 
point, the most important factors in the production of deformity. 

When the body is bent forward, as in the stooping posture, 
the intervertebral discs are compressed and the pressure upon the 
vertebral bodies is increased. When the body is held erect or is 
bent backward this pressure is lessened, and a part of the weight 
is transferred to the articular processes and to the posterior parts 
of the col i mm. The object of a brace or other support is to hold 



TUBERCULOUS DISEASE OF THE SPINE. 67 

the spine in this extended position, so that pressure on the dis- 
eased vertebrae may be removed. One aims to splint the diseased 
spine as effectively as if it were broken, in order to relieve the 
discomfort and pain, so depressing to the patient, aiid to secure 
the rest that is essential to repair. 

The effectiveness of a particular splint or support, whether 
applied to a broken bone or to a diseased spine, depends upon the 
area that it covers on either side of the part to be supported, and 
upon the accuracy of its adjustment, as well as upon the damage 
that the part has already sustained, and the strain to which it 
still may be subjected. 

From this standpoint it is evident that it is difficult to apply 
effective support to the trunk because of its size, shape, and con- 
tents, and it is apparent also that the mechanical conditions are 
more favorable in some parts than in others. For example, the 
splint is likely to be effective when the disease is of the lower 
dorsal region, because its two extremities, attached to the pelvis 
and to the shoulders, are equidistant from the point to be sup- 
ported. These conditions are reversed in disease of the upper 
thoracic region, because the weight of the head and of the arms 
tends to increase the deformity, and because of the insufficient 
leverage that can be secured for the supporting appliance. The 
pelvis is the base of support for all forms of splints, and if it be 
smaller than the abdomen, as in infancy, the adjustment of effi- 
cient support is more difficult than in older subjects. 

In actual practice the treatment of Pott's disease is influenced 
by the age of the patient, the situation of the disease, the dura- 
tion of the deformity, and by many other circumstances, but the 
relative efficiency of braces or other appliances may be decided 
on purely mechanical grounds. Thus, as the ultimate deformity 
of Pott's disease is, in great degree, caused by the force of gravity 
acting on a /reakened spine, the most effective treatment must be 
fixation in the horizontal position, for in this position the strain 
of use and the pressure of superincumbent weight can be removed 
completely; and relief from jars and strains that favor the exten- 
sion of the disease can be assured. 

Horizontal Fixation. Apparatus for this treatment musl !><• 
quite independent of the bed on which it may be placed, and of 
such appliances several forms may be employed. 

The reclinationgy psbettes of Lorenz 1 is simply a posterior 
of plaster-of-Paris enclosing the head and body. 

1 Hoffa. Lehrbuch der OrthopSdiseheD Chir., ?A ed., i>. 824. 



68 



ORTHOPEDIC SURGERY. 



The Phelps bed is somewhat similar. A thin board is cut in 
the outline of the child's body and extended legs. It is padded 
with wadding and covered with cotton cloth ; the patient is then 
placed upon it, and plaster bandages are applied to enclose the 
body and the legs. The front is then cut away, so that the 
patient may be removed from the bed for an occasional bath and 
change of clothing. 1 



Fig. 28. 




Bradford's bed-frame. (Bradford and Lovett.) 

The wire cuirasse has been popularized by Sayre f it is an 
effective appliance, although somewhat cumbersome and expen- 
sive. 

An effective and convenient form of support is the Bradford 
frame or stretcher. This is a rectangular frame a few inches 
longer and slightly wider than the patient's body. Over the 
frame covers of strong canvas are drawn tightly by means of 

Fig. 29. 



M 



jLL 



lul.m.LlUUu ill nil, 



The modified frame with the bandage. 

corset lacings or straps on its under surface, leaving an interval 
beneath the buttocks for the use of the bed pan (Fig. 28). 

The efficiency of this appliance may be increased by changing 
it in several particulars, and the following description applies to 
the apparatus used by the writer : 

The stretcher frame is made of ordinary galvanized gas-pipe 
or of steel tubing of a smaller diameter. It should be about four 



i The Phelps Plaster-of-Paris Bed. Trans. Amer. Ortho. Assoc., 1891, vol. iv. p. 
2 La gouttiere de Bonnet. Re<lard, Chir. Orthopedique, p. 243. 



TUBEBCULOUS DISEASE OF THE SPIXE. 



69 



inches longer than the child and about four-fifths as wide, the 
lateral bars corresponding to the articulating surfaces of the four 
extremities with the trunk. The ordinary dimensions are seven 
and one-half by thirty-eight inches, or the width to length about 
as one to five. 

At first thought it would seem that the side bars might cause 
uncomfortable pressure on the overhanging shoulders, but as the 



Fig. 30. 





| '^^?^7-7\ 



The stretcher frame, showing the canvas cover and apron. 

arms are set upon the middle of the lateral aspect of the trunk 
and thus on a considerably higher plane than the dorsum, there 
is but bare contact when the cover is fairly rigid. Before apply- 
ing the cover one may with advantage wind bandages tightly 
about the frame at the point which is to support the trunk in order 
to make the support as unyielding as possible (Fig. 29). The 



Fig. 31. 




The frame bent to assure overextension of the spine. The recession of deformity obtained 
in this case is shown by the tracings, Fig. 27. 



cover should be of strong canvas suitably protected in the centre 
by rubber cloth. This is applied and is drawn tight by means 
of corset lacings and straps. Upon this two thick pads of fell 
are sewed; these should be about seven inches in length and 
about three-quarters of an inch in thickness, so placed as to pass 
on either side of the spinous processes at the -eat of the die 
thus protecting them from pressure, fixing the pari more firmly, 



70 OR TH OPE DIC SURGER Y. 

and increasing the leverage of the apparatus. The child, wearing 
only an undershirt, stockings, and diaper, is placed upon the 
frame and is fixed there usually by a front piece or apron similar 
to that used with the spinal brace. As soon as the patient has 
become accustomed to the restraint, one begins to overextend the 
spine by bending the bars from time to time upward beneath the 
kyphosis with the aim, as has been stated, of actually separating 
the diseased vertebral bodies and obliterating all the physio- 
logical curves of the spine, so that the body shall be finally bent 
backward to form the segment of a circle. The greatest con- 
vexity is at the seat of the disease, and as the head and lower 
extremities are on a much lower level, an element of gravity 
traction is present in some instances, while the support of the 
spine, as a whole, is much more comprehensive than when the body 



Fig. 32. 




The modified stretcher frame, showing overextension of the spine, with traction for the 
head and limbs as applied for Pott's paraplegia. Caused by disease in the upper dorsal 
region. (See Fig. 53.) 



lies upon a plane surface (Fig. 31). The gradual overextension of 
the spine by bending the frame in this manner is so definite and 
simple that it may be easily carried out by the physician, and it 
may be exaggerated slightly to compensate for the sagging of the 
cover. Thus, it is far more effective than any form of padding 
or other form of support with which I am familiar. Upon this 
frame the child lies constantly, its clothing being made suffi- 
ciently large to include the apparatus, thus assuring additional 
fixation. Once a day in most instances the child is removed 
from the frame and is carefully turned face downward upon 
a large pillow ; the back is then inspected, bathed with alcohol 
and powdered, and the apparatus is then reapplied. It is, of 
course, desirable to have two equipped frames, but this is by no 
means essential. 



TUBERCULOUS DISEASE OF THE SPISE. 71 

The effect of the continued fixation upon the back is not 
merely to change the contour of the spine, but of the entire trunk 
as well ; to flatten and broaden the body. This increase of the 
lateral at the expense of the anteroposterior diameter is quite the 
reverse of the natural tendency of the deformity, and it is, there- 
fore, a favorable rather than an unfavorable effect of the treat- 
ment. The same tendency in the lower region may be checked 
by the use of a flannel binder, such as is ordiuarily worn by 
infants. 

Fig. 33. 




A perfect cure obtained by the stretcher treatment. The situation of the disease is shown 
in the X-ray picture, Fig. 34. 

The method of attaching the patient to the frame varies some- 
what according to the situation and character of the disease;. I n 
ordinary cases, as has been stated, a canvas apron, similar to thai 
used with the back brace (Fig. 41), is applied, and is buckled to 
the sides of the frame. If advisable the shoulders may be held 
down by straps crossing the chest, or by axillary straps connected 
by a chest band. If still more effective fixation is desired, as in 
disease of the upper dorsal region, the anterior shoulder brace, as 
used with the back brace (Fig. 39), may be attached to the axil- 



72 



ORTHOPEDIC SURGERY 



larv straps. In disease of the upper and middle regions of the 
spine restraint of the legs is not necessary, but in lumbar disease 



Fig. 34. 




An X-ray picture of the case (Fig. 33) before treatment. The situation of the disease at the 
junction of the first and second lumbar vertebra; is indicated by the lateral deviation, and 
by the approximation of the dotted lines 1 and 2 as compared to the others. 



TUBERCULOUS DISEASE OF THE SPIXE. 73 

a broad swathe should be passed across the thighs, and if psoas 
spasm is present traction may be employed. 

In disease of the upper region of the spine a certain amount of 
traction is desirable to aid in the reduction of deformity and to 
prevent the patient from raising the head. This traction is 
usually applied by means of the halter as used with the jury 
mast. The straps are attached to a crossbar at the upper extrem- 
ity of the frame, and traction may be made by simply tightening 
them, or if the upper part of the frame is somewhat elevated the 
weight of the patient's body makes the proper extension. This 
position has the advantage, also, of allowing the patient a better 
opportunity to see what is going on about him (Fig. 32). 

In disease of the middle cervical region traction is usually of 
service, and fixation of the head is always indicated in addition 
when the occipito-axoid region is involved, either by sand bags 
on either side, or, preferably, by some form of metal brace. 

Greater fixation of the spine may be desirable in cases of more 
acute disease. This may be attained by the use of a light back 
brace, or a plaster jacket, in connection with the frame. Such 
support should not be applied, however, until the recession of 
deformity, which is to be expected under treatment by the hori- 
zontal fixation and overextension, has been obtained (Fig. 27). 

As this frame is simply a horizontal brace the child may 
spend as much time in the open air as would be practicable were 
any other appliance used. 

Personally, I have never seen other than favorable results from 
this method of treatment. Pain and discomfort are, as a rule, 
relieved almost immediately, and there is a corresponding im- 
provement in the general condition of the patient. Meanwhile 
the growth of the trunk, which is so often checked by the dis- 
ease and by the deformity, appears to progress with normal 
rapidity, so that the apparatus may be actually outgrown before 
the termination of this part of the treatment. Horizontal fixa- 
tion is, of course, a treatment not complete in itself, since it must 
be supplemented by the usual supports when the erect attitude is 
again assumed. Its duration varies from six to eighteen months. 
The indications for its discontinuance are the correction of deform- 
ity, the apparent quiescence or cure of the local disease as indi- 
cated by the physical signs, and by the behavior of the patient, 
who, as repair advances, becomes restless when removed from the 
frame, evidently desiring to sit and to stand. 

At this stage it is well to apply the ambulatory support <om<- 



74 ORTHOPEDIC SURGERY. 

time before the patient is released from the frame, allowing little 
by little the changes in attitude and habits. If the plaster jacket 
is to be used it may be applied during longitudinal suspension or 
otherwise, after which the child is immediately replaced upon the 
frame, where the plaster is allowed to harden ; thus it holds the 
spine in an attitude to which it has become accustomed. (Fig. 58.) 
Ambulatory Supports. The two types of ambulatory sup- 
port^ are the steel brace and the plaster jacket. 

Fig. 35. 




The Taylor brace and head support applied for disease of the upper dorsal region. 



The Back Brace. The spinal brace, or spinal assistant, as the 
original appliance of Dr. C. F. Taylor was called, consists essen- 
tially of two steel bars that are applied on either side of the 
spinous processes from the top to the bottom of the spine. At 
the seat of the disease pads are placed to provide for greater 
pressure and fixation, and to form a fulcrum over which the 
spine may be straightened or held erect, when the two extremities 



TUBERCULOUS DISEASE OF THE SPIXE. 



75 



of the brace are firmly attached to the pelvis and to the shoulders. 
The attachment at the lower end is made by means of a pelvic 
band of sheet steel (gauge 18) from one and a half to two inches 
in width, long enough to reach from one iliac spine to the other ; 
it is placed as low as possible on the pelvis ; in other words, just 
above the upper extremities of the trochanters. To this the 
uprights are firmly attached at an interval of from one and a 
quarter to one and three-quarter inches from one another, so that 
the spinous processes may pass between them, while pressure is 
made on the lateral masses of the vertebrae. The uprights are 
made of varying strength, according to the age of the patient, 
usually about one-half an inch in width (of gauge 8 to 12) and of 
such quality of steel that, although unyielding to the strain of use, 
it may be readily bent by wrenches, and thus accurately adjusted 
to the back. The uprights reach to the root of the neck, or to 
about the level of the second dorsal vertebra; from this point 
two short arms of metal project forward and outward on either 
side of the neck, reaching to about the middle of the clavicles. 

To these padded shoulder straps are 
attached, which pass through the 
axillae to a crossbar on the back 
brace ; thus, downward pressure 
on the shoulders is avoided and 
increased leverage is assured (Fig. 
35; 

Opposite the area of disease two 
strips of thin steel about three inches 
in length are fixed ; these are slightly 
wider than the uprights aud arc 




Fig. 37. 




The Taylor chest 
The Taylor hack brace. (U. L. Taylor.) of hard rub 



o triangula: 
a bar. 



76 



ORTHOPEDIC SURGERY. 



perforated for the attachment of the pressure pads. These may 
be made of layers of canton flannel or felt, or unyielding mate- 
rial, such as leather or hard rubber, may be used instead. The 
pads should project from a quarter to a half -inch in front of the 
uprights in order that firm and constant pressure, to the extent 
that the skin will tolerate, may be made at the seat of disease 
(Fig. 36). 

In measuring for this brace the patient is placed in the prone 
posture and a tracing of the outline of the back is made by means 



Fig. 38. 



Fig. 39. 




Backward traction on the shoulders fixes 
the upper dorsal region. 



The anterior shoulder brace and its 
attachment. 



of the lead tape. This outline may be cut in cardboard and fitted 
to the back ; in fact, if the mechanic is unfamiliar with the work, 
each part of the brace, uprights, pelvic band, etc., may be cut in 
cardboard and attached to one another to serve as a model. 
Before the brace is finished it should be applied to the back and 
should be adjusted carefully by means of wrenches. The pelvic 
bund and the parts that come in direct contact with the skin are 
usually covered with leather, or, in the treatment of young chil- 
dren, with rubber plaster and canton flannel to prevent rusting. 



TUBERCULOUS DISEASE OF THE SPIXE. 



i i 



If the brace is applied before the stage of deformity it should 
follow the exact shape of the spine, but if deformity is present, 
particularly in disease of the thoracic region, it should be made 
somewhat straighter, in order to permit a gradual correction of 
the compensatory lordosis in the lumbar region, and for increased 
leverage above the deformity. As has been stated, a certain 
amount of recession of deformity can be obtained by rest in the 
horizontal position, and if practicable this improved contour 
should be attained before the brace is applied. The apparatus is 
held in place by an " apron " (Fig. 41), which covers the chest 
and abdomen, to which straps are attached. Ordinarily this is 
made of strong linen or cotton cloth, but a canvas front shaped 
accurately to the body and strengthened with whalebone, is a 
more comfortable and efficient support. In applying the brace 
the pelvic band is first attached to the apron, then the straps in 
order, from below upward, and, finally, the shoulder straps. 
Each strap is tightened until the brace is firmly fixed in proper 
position. When a brace is properly applied and properly fitted 
it holds its place by friction, but when the disease is of the 
lower lumbar region, or if the brace has a tendency to upward 
displacement perineal straps should be used to hold the pelvic 
band firmly in its place (Fig. 36). At first the brace is removed 
once a day in order to wash and powder the back, the same care 
being observed in moving the child as in the treatment by the 
frame ; but when the skin has become accustomed to the pressure 
the brace should be removed only at infrequent intervals, and 
thus, if desirable, only under the supervision of the surgeon. 

This description indicates the essential qualities of the back 
brace. It has been modified in various ways ; for example, Dr. 
Taylor long since discarded the straight pelvic band in favor of 
one of a U-shape (Fig. 36). This makes the brace somewhat 
lighter and relieves the sacrum from pressure, but it does not add 
to its effectiveness. The efficiency may be increased, however, by 
improving the attachment at its upper extremity, as is illustrated 
in Fig. 37, in which two triangular pads of hard rubber connected 
by a metal bar are employed. 

This is an improvement on the simple shoulder straps of the 
original brace, but it does not provide the quality of support and 
fixation that is desirable when the disease is of the upper or 
middle segment of the thoracic region. Iu such cases the upper 
part of the chest is flattened, the inclination of the ribs is in- 
creased, and the shoulders droop forward, carrying with them the 



78 



( > R T HOPE DIC S UIl GER Y. 



scapulae. Thus, the weight and the strain of the motion and use 
of the arms tend to increase the deformity. 

In health direct forward or reaching movements of the arms 
arc always accompanied by an increase in the posterior curvature 
of the dorsal spine. On the other hand, if the shoulders are 
drawn backward and held in this attitude, the curvature of the 
spine is lessened and the chest is elevated and expanded (Fig. 38). 



Fig. 40. 




The Taylor back brace and head support combined with the Whitman anterior support. 

In the treatment of disease of the upper dorsal region it should 
be the aim, in the application of a brace, to follow this indi- 
cation and to apply pressure directly upon the extremities of the 
shoulders to assure the greatest possible fixation of the spine and 
to restrain the movements of the arms that tend to increase the 
deformity. 

The accompanying diagrams (Fig. 39) show how such support 




TUBERCULOUS DISEASE OF THE SPIXE. 



79 



may be applied. Two saucer-shaped plates of hard rubber or 
padded metal (Fig. 40) cover the heads of the humeri aud are joined 
by a rigid bar of steel, which passes across but does not touch the 
chest. On the back brace are placed two triangular pads of 
similar construction which cover and press upon the scapula?. 
These pads are, however, not essential and are often omitted. 
The back brace is applied, the shoulders are then drawn back- 
ward and the shoulder-cups are firmly attached by straps to the 
neck bars of the brace above, and by axillary bands below in the 
usual manner. By this means the thorax is elevated and the 



Fig. 41. 



Fig. 42. 





The anterior shoulder brace. 



The scapular pads. 



spine is more effectively fixed, while direct movement of the arms 
forward is made impossible. It would seem that such restrainl 
would be irksome to the patient, but in an extended use of the 
apparatus this has never caused complaint. In many instances, 
even when the disease is as low as the tenth dorsal vertebra, it 
may be used with advantage, but it is especially indicated when 
the disease is in the neighborhood of the seventh dorsal vertebra. 
In connection with the shoulder brace it is usually advisable tr, 
apply a support beneath the chin to prevent tie' forward inclina- 
tion of the neck and to tilt the lead somewhat backward. A 



80 



nirriWPEDIC SURGERY. 



very simple and inoffensive support of this character is a loop of 
steel surrounding the neck and attached by screws to a back bar 
on the brace (Fig. 43). If a more efficient brace is required, as 
when the disease is of the upper dorsal or cervical regions, the 
Taylor head support should be used. This is an oval ring of 
steel which may be clasped about the neck by means of a lateral 
hinge. On the front a cup of hard rubber supports the chin and 
behind the ring fits upon an upright pivot that may be raised or 
lowered upon a crossbar on the upper part of the brace; free 
lateral motion is allowed, or it may be checked by means of a 
screw (Fig. 45). 

If absolute fixation of the head is indicated, as in disease at or 
near the occipito-axoid region, two steel uprights may be attached to 
the back of the ring ; these are bent to fit the posterior and lateral 
aspect of the head closely, 
and a band of webbing is 
passed from one upright 
to the other and about 
the forehead. 

In applying the sup- 
port the chin should al- 
ways be tilted slightly 
upward in order to throw 

Fig. 43. 



Fig. 44. 





The loop head support. 



Disease of the middle cervical region, showing 
the deformity and attitude. This patient had been 
paralyzed for one year before treatment was begun 
(See Fig. 45.) 



TUBERCULOUS DISEASE OF THE SPINE. 



81 



the weight of the head backward (Fig. 45). The adjustment of 
the head support is made easier if the pivot is attached to the 
upright by means of a ball and socket joint (Shaffer) (Fig. 35) 
that may be regulated by a screw and key ; this arrangement is 
of service when the head is distorted, but it is by no means 
necessarv. 



Fig. 45. 



Fig. 46. 




The Taylor brace and head support applied 
to the patient shown in Fig. 44. 



The Taylor brace with jury mast. 



When the Taylor head support or similar appliances are used 

greater part of the pressure is sustained by the chin, wind) 

may, after a time, undergo an unsightly recession. Ft may be of 

advantage, therefore, in such cases, and particularly when restraint 

of the motion of the neck i- desirable to transfer tin- pressure to 



82 OR T HOPE DIC SURGER Y. 

the forehead and occiput by extending the back bars upward 
over the back of the head, as in Fig. 51. 

A jury mast may be used to support the head also; its adjust- 
ment will be described in connection with the plaster jacket, with 
which it is usually associated (Fig. 46). 

The Plaster Jacket. It was claimed at one time that a plaster 
jacket applied while the body was partially suspended would 
actually relieve the weakened area of superincumbent weight by 
holding the diseased surfaces apart. This is not the fact. The 
jacket supports the spine as does the brace by holding it in the 
erect or extended position. One is a circular and the other is a 
posterior splint. There is this difference, however : the brace fits 
the spine accurately and holds its place by pressure and friction ; 
the jacket is held in place by the support of the projecting pelvic 
bones ; it lacks the accuracy of adjustment of the brace at the 
seat of disease, but, on the other hand, it provides a solid support 
on the front and sides of the body. 

Each appliance has advantages and disadvantages that become 
apparent in the treatment of certain phases of the disease or con- 
ditions of the patient. 

The plaster bandage is a simple support, whose efficiency 
depends upon the accuracy of its adjustment to the irregularities 
of the body, and upon the leverage that it exerts above and below 
the weakened part. It should be applied while the body is held 
in the best possible position ; its inner surface should be smooth, 
and the bony prominences that are susceptible to friction and 
pressure should be protected. 

A seamless shirt should be worn ; these are made in several 
sizes and are sold by the yard at a low price. The shirt should 
fit the body closely, and should be long enough to reach to the 
knees. On the front and back bands of linen or China silk or 
other material, about three inches in width and three feet in 
length, should be placed beneath the shirt. These bands, or, 
as Lorenz calls them, " scratchers," are for the purpose of 
keeping the skin clean. The patient is then placed upon a 
stool, and the halter of the suspension apparatus is carefully 
adjusted ; the arms are extended over the head and the hands 
clasp the straps or rings ; thus, the chest is expanded to its full 
limit. Sufficient tension is made upon the rope to partially 
suspend the body and to draw the spine into the best possible 
attitude; in most instances the heels should be slightly lifted 
from the stool. 



TUBERCULOUS DISEASE OF THE SPIXE. S3 

Dr. Sayre, to whom we are indebted for the exposition of this 
valuable means of treatment, insisted that the sensations of the 
patient should be the guide, and that traction should be made 
only to the point of comfort. This is a valuable indication in 
the treatment of the adult, but it is not often of service in child- 
hood. 

Before applying the plaster bandage pieces of piano felting or 
canton flannel of sufficient thickness are placed about the anterior 
pelvic spines, over the upper part of the sternum, and a thin 
strip is sometimes used to cover the spinous processes. Finally, 
long strips of saddlers' felt, or of other material of sufficient 
thickness, are applied on either side of the prominent spinous 
processes to protect them from friction and to provide greater 
pressure and fixation at the seat of disease. In the treatment of 
adolescent or adult females the breasts should be covered with a 
layer of cotton, which may be removed later if necessary, to pre- 
vent pressure. The * * dinner pad n is now not often used, except in 
the treatment of adults and in certain cases in which the abdomen 
is retracted. In childhood the abdomen is usually prominent, 
and in most instances no extra space is required. Occasionally, 
however, one is told that the patient complains of discomfort 
after meals, evidently due to constriction, and in such cases proper 
allowance must be made. The pad, which is supposed to repre- 
sent the space necessary after a full meal, is made by folding a 
small towel into the shape of a sandwich ; this is attached to a 
bandage and is placed beneath the shirt just below the ensiform 
cartilage; when the jacket is completed it may be drawn out 
by means of the hanging bandage, leaving the additional space 
for emergencies. 

The materials for the jacket should be of the best. Fresh 
dental plaster should be rubbed by hand into strips of crinoline, 
free from glue. The bandages should be from three to five 
inches in width and six yards in length, from three to six being 
required for a jacket, according to the size of the child. They 
should be placed on end, in a pail of warm water, one at ;i time 
as they are used. 2so salt or alum should be used to hasten the 
setting of the plaster; iu fact, if such aid is necessary, it i> unfit 
for use. When the bubbles have ceased to rise tie- band 
squeezed gently until no water drips from it. and r 1 1 ♦ - Loose threads 
are removed from the ends. 

One person should -it behind the patient and one in front, 
while a third may hold the rope and check the swaying <»f the 



g I ORTHOPEDIC 8UBGEEY. 

bod) . Fhe one who -it- behind the patient may clasp the child's 
tetween bis knees and thus assure better fixation of the 
pelvis. The pads aw held in position until they are fixed by the 
plaster bandages, which Bhould be applied with a slight and even 
tension. 

\- ,i rule, the jacket should be of uniform thickness through- 
out. Thia thickness need m>t exceed one-eighth to one-fourth of 
:m inch, and it may even be Lighter in certain cases. It is well 
to make the first turns about the waist, and to use the first band- 
ar about the pelvis, since the pelvis is the base of support; and, 
SS the most important point for counter-pressure is the chest, this 
part Bhould be made especially strong and resistant. 

During the application of the jacket it should be rubbed 
constantly, in order that the different layers of bandage may 
adh<rc to one another, and that it may fit the projections of the 
pelvifl and body closely. Meanwhile the attitude of the patient 
should be carefully watched, in order to prevent lateral inclin- 
ation of the body. In some instances it is possible to lessen the 
deformity by the extension and by backward traction on the 
shoulders and forward pressure on the trunk while the jacket is 
hardening. 

When the jacket is nearly firm it should be trimmed. In 
many instances this may be done while the patient is in the 
swing, but if he is fatigued he may be placed in the recumbent 
posture. 

Ajb a rule, the front of the jacket should reach from the upper 
margin of the sternum to the pubes; behind, from about the 
mid-lim- of the Scapulas to the gluteal fold ; laterally, it should be 
out away sufficiently to prevent chafing of the arms; and on 
either side of the pubes an oval section is cut out, to allow for 
the flexion of the thighs in the sitting posture. Particular atten- 
tion is called to the importance of making the jacket as long as 
possible . so thai the abdom< n may be contained within it instead 
of being forced out beneath its lower border (Fig. 48). After 
>n of the jacket the patient should remain in the 
recumbent posture for at Least half an hour. A much longer 
i of recumbency is always advisable, as it does not become 
absolutely firm for several hour-. The shirt is then drawn up 

' and i wed to the neck portion; this adds much 

itness and cleanliness. The shirt must be drawn tightly 

abonl the neck, in order to guard the body from the crumbs or 

ty fall beneath the jacket, and in many 



TUBEBCULOUS DISEASE OF THE SPIXE. 



85 



instances a special protector in the form of a wide collar bib may 
be nsed with advantage. 

The upper and lower ends of the cleansing bandages are joined 
to one another with tape, and with them the skin is carefully 
rubbed twice daily. When soiled they may be replaced. 



Fig. 47. 



Fig. 48. 




The plaster jacket, illustrating the 
arrangement of the shirt. 



The pla lupportlng tbe abdomen 

The cleansing !>;> 



It may be mentioned in tin'- connection thai even the Blightes! 
excoriation or irritation of the -kin beneath tin- jacket can !>«• 
detected by the peculiar odor, < >f this parents should !•«' in- 






RTHOPEDIC SURGERY. 



formed, bo thai it may !><* oul down and the source of the irritation 
removed at onoe, With ordinary care " sores," the bugbear of 
the plaster jacket, may be avoided or so quickly detected that 
are of little consequence. 
If the disease Lb of the middle region of the spine, backward 
traction on the shoulders La indicated, by means of the anterior 



FtO. 49. 




The jury mast and the anterior support. 

shoulder brace described in connection with the spinal brace 
!'.' : or, if this is do1 at hand, padded straps may be passed 
about the shoulders and attached to buckles placed on the back 
of the jacket. Traction applied in this manner aids in prevent- 
deformity and assures better expansion of the chest. 
In many instances a head support is required, and it is, of 
- indicated in disease of the upper dorsal and cer- 
vical regions. For this purpose a jury mast or a posterior sup- 
port may !>«• employed. 

Th<- jury masl should be of tempered steel, strong enough to 

hold it- shape under the tension of the halter (Fig. 50). Its 

should be incorporated firmly in the jacket below the seat 

of the disease; it should be long enough to reach well above 



TUBERCULOUS DISEASE OF THE SPIXE. 



ST 



the head, and the crossbar should be placed directly over the ears 
(Fig. 53). 



Fig. 50. 




Jury mast. 



Fig. 51. 



Fig. 52. 




A fixation support for the head. This may be 
I with the brace or with the jacket. 



Front view of the - 



- 



ORTHOPEDIC SURGER )'. 



The baiter Bhould be applied with as much tension as can be 
borne comfortably by the patient, bo that the weight of the head 
may be at leasl partly supported. The straps should be ad- 
I to tilt the chin slightly upward, the aim being to draw the 
head backward and thus to extend the spine. In disease of the 
cervical region the crossbar should be fixed to check lateral mo- 
tion of the bead, but this is unnecessary when the disease is at a 
lower level. 







and jury mast applied. The same patient is shown in Fig. 32. 



If in.. iv complete fixation of the head is desired, or if the jury 

i~ ineffective, an appliance Bimilar t<. that shown in Fig. 51 may 

•d. This consists of two light steel bars, incorporated like 

the jury mast in the jacket, and adjusted to the neck and back 

of the lead. Their upper extremities are joined by a band of 

light steel «.f U-shape, Inn- enough t<> reach from ear to ear, the 

circumference being completed by a band of tape across thefore- 

In certain instances additional straps may be placed be- 

. the chin and the occiput, as in Figs. 51 and 62. In this 



TUBERCULOUS DISEASE OF THE SPIXE. 



89 



connection it may be stated that the support provided by the jury 
mast is only effective when it is carefully adjusted and carefully 
watched. In most instances, therefore, a rigid apparatus, though 
less comfortable, is to be preferred. 



Fig. 54. 




The application of the jacket in the recumbent posture by means of the Goldthwait appli- 
ance. .4, the support, similar to that upon which the patient is lyiug ; B, two thin bands of 
steel, similar to those used in the Taylor brace. 

Fig. 55. 




R, Tonstall Taylor's apparatus for the application of the planter jacket in the recumbenl 
posture, consisting of an adjustable back support and pelvic rest connected by a sliding 
See Fig. 56.) 

The Application of the Jacket in the Recumbent Posture. The 
jacket may be applied while the patient lies extended in the prone 
posture, by the hammock method suggested by Davy, of London. 






RTHOPEDIC SUBOEM P. 



A long, narrow -trip of cotton cloth is passed under the shirt 
and is drawn tighl enough, by means of a pulley or by manual 
traction, to support the child in the.proper attitude, preferably, 
of course, in overextension. An opening is cut for the face, and, 
if advisable, traction may be made on the arms and legs of the 
patient. The oandages arc then applied in the ordinary manner, 
after which the cloth may be cut short at one end and removed. 

This method is of service in the treatment of weak or 
paralysed patient-, but the adjustment is somewhat less accurate 
than by the ordinary method. The jacket may be applied in 
the Bupine posture by means of the Goldthwait apparatus. This 
may he employed with advantage in the routine application of 
the plaster jacket, and it has supplanted in some degree the sus- 
pension method. 

Fig. 56. 




. ivlor appliance in use, showing the hyperextension of the spine. The plaster jacket 
l the bads rest is removed by pressing the bandages from side to side or 
j opening. If desirable, the defect is then concealed by a turn of plaster 

i«e. 

This consists essentially of a support (Fig. 54) carrying on its 
upper extremities two thin strips of perforated metal. To these 
strips, fell is attached, forming pads similar to those used on the 
back brace. The patient is then placed with his back resting on 
tli" pads :it the seat of the disease. The buttocks and the head 
are allowed to sinfc downward to the point of toleration, thus an 
extending force Is exerted on the spine. The plaster bandages 
are then applied in the usual manner about the body on either 
Bide of the support. When it Is completed the patient is lifted 
from the support, the pads being included, of course, in the 
jacket. An opening remains at this point that may be closed if 
desirable by an additional bandage. 

< Kher supports of a Bimilar nature are in use, but as they do 
not differ from it in principle a detailed description is unneces- 
>5 and 5< 



TUBERCULOUS DISEASE OF THE SPIXE. 



91 



The Application of the Jacket to Patients who have been Treated 
on the Stretcher Frame. A satisfactory method of applying a 
plaster jacket in young subjects, when the deformity has been cor- 
rected in whole or part by recumbency on the frame in the over- 
extended position, is the following : The patient L> suspended 
face downward in the horizontal position by two assistants, one 
holding the arms and the other the thighs ; thus, a certain amount 
of traction is exerted, while the weight of the body tends to over- 
extend the spine. 

In this attitude a jacket is quickly applied, and the child is at 
once replaced upon his frame, which has been protected by a 
rubber sheet (Fig. 57). The plaster jacket, during the hardening 
process, must conform to the habitual posture of recumbency. 
The pressure pads of the frame indent the bandage on either side 
of the spinous processes (Fig. 58), and thus afford better sup- 
port and fixation. This is a very satisfactory method of apply - 



Fig. 57. 




The stretcher frame on which the patient is replaced while the jacket is hardening. 

ing the jacket in this class of cases, because it is not necessary to 
retain the child in an uncomfortable position while the bandage 
is hardening, and because accuracy of adjustment in the besi 
possible attitude is assured. 

These methods, in which the object is to overextend the spine, 
are especially indicated in cases in which the deformity is Blight. 
If it is fixed and well marked, suspension is preferable. 

A- a rule, a jacket may be worn for two months, although n«»t 
infrequently it may remain for six months, or even longer, and 
yet be fairly efficient. Usually one jacket i> removed and 
another applied on the same day, but if tin- -kin is at nil sensitive 
it is well, after the washing and powdering, to reapply the old 
jacket, closing it with adhesive plaster, and allow an interval of 
a few days before applying the permanent one. 






ORTHOPEDIC SURGER 7. 



The Piaster Corset. In the Btage of recovery the jacket may 
be replaced by a corset A jacket, made and trimmed as already 
ibedj 18 oul down the centre and removed from the body. 
It [a carefully readjusted to its former shape, bandaged with the 
cut surfaces in close apposition, and is thoroughly dried or 
baked. All wrinkles are then cut away from the inner surface, 
and extra padding is applied if necessary; the shirt is drawn 
tightly aboul the borders of the jacket and strips of leather pro- 
vided with books are sewed in front so that it may by laced like 
an ordinary corset It may be removed from time to time to 
allow for bathing, but it should always be removed and reapplied 
while the patient i> suspended or in the recumbent position. 



Fig. 58. 




method, .bowing the depressions on either side caused by 
the name pads. 

The cornet i- sometimes used in place of the jacket during the 
J "" f,l "" ll -' ;| -'' '"" " i- ^ effective, since the repeated 

durin 8 IV wl and ^application weakens the appli- 

: ''"' '"'" ""l"'"- ' ll - : "<■■■»■>■ of adjustment. [„ addition, one 

-"'"">"- i„ favor of the use of plaster of Paris 
thai treatment i- under the control of the surgeon, is nullified 



TUBERCULOUS DISEASE OF THE SPINE. 93 

Comparison of the Two Forms of Ambulatory Support. The 
most severe criticisms of the jacket have been made by those 
unfamiliar with its use, on theoretical grounds rather than from 
actual observation. While it may be admitted that there are 
certain objections to the support, yet experience has shown that 
when it is applied in a proper manner under proper conditions it 
is a thoroughly reliable, efficient, and often indispensable means 
of treatment. Indeed, it may be stated that by means of the 
jacket and the stretcher frame it is possible to treat nearly every 
case of Pott's disease without the aid of the professional brace- 
maker, and with success. 

It is evident, however, that under certain conditions the jacket 
must be inferior to the brace, in early childhood for example, 
when the pelvis is not sufficiently developed for proper support. 
Again, when the disease is low down, at or near the lumbosacral 
junction, the lower border of the jacket does not hold the pelvis 
with sufficient security to provide the proper fixation. In the 
upper dorsal region the attachments for accurate fixation may be 
adjusted more readily to the brace, and in disease of the cervical 
region the metallic head support is to be preferred to the halter 
of the jury mast, for the reason that it cannot be removed by the 
patient. The traction of the jury mast is very effective when 
properly used, and particularly so when painful distortion of the 
head is present, but the tension on the straps is rarely constant, 
and thus loses in efficiency. A rigid support is, of course, prefer- 
able in the disease of the atlo-axoid region. 

The jacket is most serviceable in the region from the tenth 
dorsal to the second lumbar vertebra. It is not only effective, 
but it is often a more comfortable support than the spinal brace. 
It is more efficient than the brace when lateral deviation of the 
spine is present ; and from the clinical standpoint it is often more 
efficacious in relieving pain in this region when the disease is at 
all acute. One may conclude, then, that each form of support 
may be used according to the indications. The absolute control 
of the treatment, assured by the use of the plaster jacket, will 
often overbalance the claims of the brace. In practice among 
the poor, when choice of means is not always permitted, it is indis- 
pensable; and it may be used with fair success even under con- 
ditions that theoretically contraindicate its employment 

Modifications of the Jacket. Occasionally, the form of the 
jacket may be changed to meet special indications; for example, 
backward traction may be secured by carrying the bandages over 



!•» 



ORTHOPEDIC SUBQEB V 



the shoulders; or the bead may be fixed in the support, if the 
jury mad is ao( at band (Fig. 59) j or one or both thighs may 
be included in a -pica jacket in painful disease of the lower region, 
when peoafl spasm is present Such modifications are required 
rather for emergencies than for continuous treatment. 

Dr. II. L. Taylor has recommended what he calls the bivalve 
plastic Bplinl of plaster of Paris. 

• \ paper pattern of the posterior valve is made from the 
patient's back, allowing ^nr inch extra around the edge to be 

Fig. 59. 




I il ne in the extended position, as applied for 
the uj>i>er dorsal region. 

folded l»a<-k. Prom this pattern eight or ten thicknesses of 
crinoline >f the same size and shape. The patient being 

supported face downward on a rest under the pelvis and another 
under the npper part <>f the sternum, the crinoline sheets are 

1 into plaster cream in a large flat pan, applied to the back, 
the Mr pads being in position ; the edges are folded back for 

r rigidity and the whole carefully moulded to the patient 



TUBERCULOUS DISEASE OF THE SPIXE. 95 

and allowed to set, after which the patient is turned on his back 
and the anterior valve made in a similar manner. 

• • The support should be made firm and rigid, especially at the 
edges, and should reach in front from the pubes to the top of the 
sternum. Such an apparatus is rigid, removable, and adjustable, 
and brings the pressure to bear on definite areas selected with 
regard to its mechanical action. The splint may be removed to 
cleanse the back or to note its efficiency, taking the impressions 
made by the felt pad either side the spinous processes as a guide. 
If more leverage is needed, the felting may be reinforced or the 
depth of casing reduced by paring the lateral edges. In other 
words, the jacket has ceased to be mainly a casing and has become 
a mechanism under the surgeon's control and capable of being 
manipulated to produce definite mechanical results." 

Corsets of Other Material Than Plaster of Paris. Corsets of 
wood, leather, paper, poroplastic felt, and celluloid are sometimes 
used. These are constructed on a plaster cast of the body, a 
thin, accurately fitting jacket being used as a mould. 

Fig. 60. 



The Thomas collar of leather stuffed with cotton. (Ridlon and Jones.) 

Such corsets have certain advantages of durability and elegance, 
but none of them has the accuracy of fit of the plaster-of- Paris 
corset, which is moulded directly on the body by constant manipu- 
lation during the stage of solidification. Corsets of this class are 
usually somewhat expensive, and on that account are often worn 
after they are outgrown or when they no longer fit the patient. 
Their use is practically limited to the stage of recovery or for 
other affections than Pott's disease. 

Of these corsets, one of the best is that used by Weigel, of 
Rochester, made of alternate layers of linen cloth and wood-pulp 
matrix paper, fixed by a mixture of paste and glue. 

A more durable corset may be constructed of alu min u m , ;i- 
suggested by Phelps. This may be obtained in thin sheets, 
which may be hampered upon a metal cast of the trunk into the 
proper shape. The two halves are attached by hinges in the 
back and are perforated to allow for ventilation. 

In the final stage of treatment, the Knight brace, .1 light 



ORTHOPEDIC SURGERY. 

frame with corset front, may be employed (Fig. 143) or a long 
corset similar to thai ordinarily worn by women, but strengthened 
by the insertion of light steel bars along the spine, may be sufficient 

Other Forms of Support. I n certain cases of disease of the lower 
lumbar region of the spine it may seem advisable to restrain the 
movements of the thighs, although ordinarily, when this is neces- 
Bary, ambulation Bhould be discontinued. Such restraint may be 
attained by making the back bars of the brace stronger and 
extending them down the back of the thighs to the knees like a 
double Thomas hip brace. 

If the jacket is \\>vi\ it may be extended to a single or double 
-pica for the same purpose as has been mentioned. Such appli- 
ance- are useful when psoas spasm and " cramp " are troublesome 
symptoms. 

Fig. 61. 




The Thomas collar for permanent use. A piece of thin sheet metal is cut wide enough 
b from the sternum to the chin, and from the back of the neck to the base of the 
OOOlptlt The edges are turned out and the whole properly covered with felt and fitted. 
;ind Jones.) 

In disease of the cervical region a certain amount of support 
and fixation may be obtained by collars of poroplastic felt, 
plaster of Pari-, or other material. The Thomas collar (Figs. 60 
and 61 is the best of this type of support, but none of them is 
thoroughly efficient unless used with a brace to control the larger 
movements of the Bpine. They are useful in emergencies, but 
ire not often required when proper braces can.be obtained. 

Many other forms of apparatus of greater or less merit might 
be described, but space has permitted only a detailed account of 
three forms that, it would seem, best represent the essential prin- 
ciple involved in the treatment of Pott's disease. 

The Principles of Treatment in Their Practical Application. 

Alter the description of the special forms of appliances used in 

DUtine treatment of Pott's disease, one may consider with 

advantage the treatment in its more direct relation to the patient. 

The object of this treatment is to relieve the symptoms, to main- 



TUBERCULOUS DISEASE OF THE SPIXE. 



97 



tain and to improve the vital resistance of the patient, to check, 
to remedy, and to prevent deformity. Under favorable con- 
ditions the death-rate is small, and pain is easily relieved, but 
prevention of deformity is often extremely difficult 

The effect of treatment must be estimated not simply by its 
relief of the symptoms of the disease, since deformity may steadily 
advance in spite of the apparent well-being of the patient, but it 
must be selected and continued or changed with the aim of com- 
bating ultimate deformity, and on this standard success or failure 
must be determined. It is probable that noticeable deformity 



Fig. 62. 




The Thomas collar applied. (Rid Ion and Jones. 



might be prevented, nearly always, if treatment were applied in 
season. But practically such opportunity is not often offered, 
and the local deformity that represents destruction of bone may 
be considered as irremediable. There is also a dwarfing and 
blighting effect of the disease, which, although it is usually 
ciated with marked deformity, is always to be feared, particularly 
when the disease affects the middle or lower regiofl of the ^]»in< i 
in early childhood, and is severe and prolonged in it- course. 
By proper treatment one may hope to check the progress of tin- 
disease and even to remedy the deformity in great degree by free- 
ing the spine from the deforming influence of local disease, and 

7 






ORTHOPEDIC SURGERY. 



I, v preventing or removing the symptomatic distortions such as 
l^..;i> nuitnu'tion or wryneck. 

Indications for Treatment by Recumbency. As has been stated 
already, the most important influence toward deformity when the 
spine has been weakened by disease is the force of gravity; 
therefore, horizontal fixation in overextension is the most efficient 
means of preventing deformity, and it assures the rest for the 
diseased -pine that favors repair. 



Fig. 63. 




of the middle dona] region, a type of disease in which horizontal 
fixation is always indicated. H. S., aged fourteen months. 



Thia ifl alwaye the treatment for emergencies and in many 
instances the treatment <>f choice and routine. It is indicated as 
the routine treatment in infancy and in early childhood up to the 
ears al Least. 

In many instances absolute recumbency may not be required, 
but the period of activity musl be carefully regulated, and must 
!»•• discontinued when there is evidence of discomfort or weakness 
(,r pain. If the period of activity musl be short, it should be 
pa— ed in tlic <>|>cn air. The passive attitude of sitting, although 
les- -train i- thrown upon the -pine than during activity, may be 



TUBERCULOUS DISEASE OF THE SPINE. 



99 



even worse for the patient ; thus, the reclining or semi-reclining 
posture should be assumed as a rule, when the child is in the 
house, at least during the active stage of the disease. Even if 
the spine appears to be perfectly supported, the time spent in 
bed should be long, and a period of rest in the middle of the day 
should be enforced. 

The arguments in favor of horizontal fixation in early child- 
hood do not apply to disease in the adult. At this stage the 
structure of the spine is resistant, and deformity is little to be 
feared, while such confinement would be irksome and impracti- 
cable ; thus, local support, supervision, and, if possible, a change 



Fig. 64. 




H. S., after fourteen months of fixation on the modified Bradford frame, shows 
the recession of deformity. Compare with Fig. 63. 

of climate, must be the treatment of selection for the adolescent 
or adult. 

In the middle period of childhood, from the fifth to the tenth 
year, horizontal fixation is the treatment for emergencies; for 
paralysis, for abscess, for dangerous disease of the atlo-axoid 
region, for progressive deformity, and for pain that cannot !><• 
relieved by the ordinary means. 

Special Indications for Treatment of Disease of the Differ- 
ent Regions of the Spine. In the selection of treatment, and 
in the general management of Pott's <li-<;i~'-, each region of the 
spine must be judged by itself, since in each there are special 
difficulties to be met, and complications to l>e feared that may 



lni» 



ORTHOPEDIC SURGERY. 



influence the prognosis and lead to modifications of the routine of 
treatment. 

The Lower Region. The prognosis is good in disease of the 
Lower region, the symptomatic attitude 1 is favorable, the part may 
supported easily, the cases arc often seen before the deformity 
• all extreme, and one may, as a rule, predict recovery with- 
out ] noticeable deformity, at most, 
l)ti t a slight shortening and broad- 
ening of the body and a peculiar 
ercctness of attitude. Uncomplicated 
cases may be treated with the brace 
or jacket. The brace is the better 
support when the disease is near the 
sacrum, while the jacket is often 
more comfortable and more effective 
than the brace when the middle or 
upper lumbar region is diseased, par- 
ticularly when lateral deviation of 
the spine is present. Whenever the 
tendency to psoas contraction is at 
all marked or when pain or cramps 
in the legs are complained of, the 
period of activity should be care- 
fully restricted; in fact, the " night 
cry " is an indication for a day of 
rest in bed. 

The most troublesome complica- 
tions of this region are psoas con- 
traction and the abscess with which 
it is often combined. 

A- lias been stated, psoas contrac- 
tion changes the attitude of over- 
erectness, favorable to repair, to a 
of lumbar dtteue; spon- forward stoop that increases the 
■ ! " n,nl pressure and friction at the seat of 

slight <!• ' 

disease. If this attitude persists and 
if it becomes fixed by permanent changes such as are likely 
to follow tli*- burrowing of a pelvic abscess, most disastrous 
deformity may follow; the body and the thighs are approx- 
d and thi attitude is made impossible. In neglected 

of this character, tenotomy and forcible correction or even 
subtrochanteric osteotomy may be necessary to overcome the 




TUBERCULOUS DISEASE OF THE SPINE. 101 

secondary deformity. In ordinary cases of psoas contraction, 
and when one limb only is flexed, the patient may be allowed to 
go about using a high shoe on the unaffected side, and crutches, 
so that the flexed leg need not affect the attitude. If, however, 
the contraction persists, it is well to place the patient on a frame, 
aud to reduce the flexion by traction in the line of deformity, as 
will be described in the treatment of disease of the hip-joint. 
Persistent psoas contraction is almost always a symptom of 
abscess about the origin or in the substance of the muscle, and 
when it is accompanied by pain it is always an evidence of pro- 
gressive disease. 

Abscess may be expected as a complication in at least 50 per 
cent, of the cases of disease of this region, but it is by no means 
always accompanied by psoas contraction, any more than psoas 
contraction is always caused by abscess. Abscess unaccompanied 
by contraction more often has its origin above the lumbar region, 
and in its descent it passes along the surface without involving 
the substance of the muscle. 

Attention is especially called to the fact that the bad results of 
Pott's disease of this region are caused almost invariably by 
allowing psoas contraction, whether it be symptomatic of abscess 
or not, to persist ; therefore, the importance of preventing and 
correcting this deformity cannot be overestimated. It should be 
stated, however, that in dispensary practice, when special care 
cannot be provided, one often sees psoas contraction that may 
have persisted for months relax, if the progress of the disease is 
favorable, without treatment other than the routine fixation of 
the spine by the brace or jacket. 

The Lower Dorsal Region. Disease of the lower dorsal region 
is very favorably situated for effective mechanical treatment, and 
psoas contraction and abscess are much less troublesome than in 
the lower part of the spine. 

Deformity sometimes increases, almost imperceptibly, by a 
progressive forward bending or lordosis of the flexible Lumbar 
spine below the projection. One must guard again-t this by 
applying the jacket firmly while the spine is made as straight as 
possible, or, if the brace is used, the lumbar spine should be 
drawn firmly against it. 

If lateral inclination of the body is so marked a- to interfere 
with the proper application of a brace, preliminary rest in bed is 
indicated. Lateral deviation can be corrected, a- a rule, by the 
jacket without recumbency, although tin-, as other form- of symp- 



IQ2 ORTHOPEDIC SURGERY. 

tomatic distortion, Bhould be treated ordinarily, if not by complete 
.it least by oarefuJ regulation of the period of activity. 

Disease of the Middle and Upper Dorsal Region. This is, from 
the standpoint of prevention of deformity, the most difficult 
r. gion of the -pine to treat, although the symptoms of the disease 
may be easily relieved. 

formity is present in nearly all cases when treatment is 
Bought, an«l. deformity having begun, is very difficult to check, 
for the reasons thai have been stated already. 

Tie- final result in the majority of cases is what appears to be 
_. rated round shoulders; the neck is shortened and projects 
forward, the ohesl is flat, and the shoulders are high. 

It is only by an early diagnosis and by efficient and long- 
oontinued treatment, bee-inning, if practicable, with horizontal 
fixation, that recovery from disease in this region without notice- 
able deformity may be hoped for. 

In all oases of disease above the ninth vertebra, the anterior 

brace for backward traction of the shoulders may be used with 

great advantage to secure greater fixation of the spine ; and in all 

above the seventh or eighth vertebra a head or chin support 

strain the forward inclination of the neck is indicated in 

addition. 

\\ itli the plaster jacket the jury mast or posterior support is 
employed ; with the brace the looped chin rest or the ordinary 
Taylor support may be used. 

I n disease of the upper dorsal region the brace is to be preferred 
to the jacket, because of the greater accuracy of adjustment, and 
because the halter of the jury mast is rarely retained in proper 
position when the patient does not, as in these cases, feel the 
'1 "f* such support 

In this region of the spine -paralysis frequently occurs as a 
complication. When it appears after treatment is begun, it is 
usually ;i resull ->f inefficient fixation of the spine or of want of 
.-anti. .11 in regulating the strain to which the diseased part is 
subjected. It- symptoms and it- treatment will be considered 

Disease of the Upper Dorsal and Middle Cervical Region. This 

is the mosl favorable region of the spine for treatment. The 

usually not extensive because of the small size and com- 

structure of the vertebrae \ and the mobility of the cervical 

real thai it readily compensates for the local rigidity. 

I ader efficient treatment one may predict recovery without 



TUBERCULOUS DISEASE OF THE SPINE. 103 

noticeable deformity, and in the less successful cases the deform- 
ity is not, as a rule, offensive. The shoulders appear high, the 
neck is short, the head inclines forward, while the back is abnor- 
mally Hat in compensation for the change in contour of the part 
above. 

When the case of cervical disease is first brought for treatment 
a wryneck deformity, often made more persistent by the infiltra- 
tion of an abscess or by enlarged cervical glands, is almost always 
present. As a means of correcting this distortion, the jury mast 
and traction halter, attached to the jacket or brace, is a very 
efficient and comfortable support. Under the constant tension 
the deformity may be corrected with ease, but as a permanent 
treatment the brace and head support are to be preferred to the 
jury mast, because a more exact fixation is assured. 

Disease of the Occipito-axoid Region. Under efficient treatment 
the prognosis is good, and recovery without deformity should be 
the rule. The course of the disease, although it is often accom- 
panied by acute symptoms, is usually short, as compared with 
that of other regions of the spine. It may be assumed that, in 
many cases, it is a primary arthritis, or, at least, that the primary 
focus in the atlas or axis is very small. The disease at this point 
is, however, in close proximity to the vital centres, and sudden 
death from displacement of the weakened parts is not uncommon. 
Abscess is frequent, and it is often a troublesome and dangerous 
complication. 

As has been mentioned, wryneck deformity is a very constant 
symptom, and there is also a strong tendency toward a forward 
and downward inclination of the head, so that in neglected cases 
the chin may rest upon the chest. The indications for treatment 
are to overcome the distortion and to hold the head fixed in the 
middle line, the chin being somewhat elevated above the right- 
angled relation with the spine. In the mild cases the jacket with 
jury-mast traction may be used to overcome the distortion, but 
the metallic head support with the fixation attachment to prevent 
motion in the diseased joints, is always indicated as the treatment 
of selection, because by such apparatus the danger of displacement 
may be avoided. 

AVhen the disease i- acute in character, and especially if abt 
is present, recumbency on the frame with fixation of the head and 
Blight traction by the weight and pulley, or by the jury-mast 
attachment, is indicated. Traction should not he sufficient to 
cause discomfort ; counter-traction may be supplied by the weight 



|,,| ORTHOPEDIC SUEOEB T. 

of the body and by Blight elevation of the head of the bed. The 
head sling may be thai used with the jury mast, or a simple 
band about the head may be used. Under this treatment slight 
deformity of any pari of the cervical region will practically dis- 
appear, and, as a rule the course of the disease is very favorably 
influenced by the period of complete rest. 

In certain cases of disease of this region, accompanied by acute 
symptoms, the attitude of recumbency is extremely uncomfortable. 
The discomfort Lb caused apparently by the forward projection of 
the upper part of the spine, so that when the head is drawn 
upward and backward in the recumbent attitude the calibre of the 
throat is lessened. In other instances the pain may be due to 
re of the atlas against the odontoid process of the axis. In 
Buch oases, if recumbency is desired, the head must be elevated 
by pillows to tie* point of comfort, the support being removed 
when the child has become accustomed to the position, or when 
the deformity lia< been corrected. 

The Complications of Pott's Disease. Abscess. It may be 
assumed that a limited collection of tuberculous fluid is present 
at some time during the course of Pott's disease in the great 
majority of cases, but unless it appears as a palpable tumor above 
<>r below the thorax <>i upon the surface of the body its presence 
is not often d< tected. 

IWnsend, 1 iu 380 cases of Pott's disease examined with refer- 

ence to the occurrence of abscess as a complication, found that it 

nt or liad beeu detected in ".") (19.7 per cent.); in 8 

lit. of the cases of cervical disease; in 20 per cent, of the 

dorsal, and in 72 per cent, of those in which the lumbar region 

was involved. 

Dollinger, 3 in 700 cases under treatment from 1883 to 1895, 

found abscess in 154 (22 per cent.); in 13 of 63 cases in the 

cervical region 22.6 p< r a nt); in 47 of 403 cases in the thoracic 

I 1.6 p , and in 94 of 234 cases of lumbar disease 

I l<». ] 7 p. 

K' teh, in 75 cured cases of Pott's disease treated at the New 

Y.. r l< Orthopedic Dispensary, selected for the purpose of con- 

trasting the behavior of the disease in the different regions of the 

. found thai abscess had appeared in 19 (25.3 per cent.). 

In the upper region abscess was detected in but 1 of the 25 cases 

rlca ' IrthopediC Association, vol. iv. p. 166. 
• r. fa n Ortl* elation, vol. iv. p. 200. 



TUBERCULOUS DISEASE OF THE SPIXE. 105 

(4 per cent.) ; in the middle region in 8 of the 25 cases (S'2 per 
cent.), and in the lower in 10 (40 per cent.). 

In 354 autopsies by Mohr, Xebel Bouvier, and Lannelongue 
abscess was found in 281, or nearly 80 per cent. Although 
cases of Pott's disease that come to autopsy may be supposed to 
represent a severe type of disease, yet it is evident, by contrasting 
the statistics, that a large proportion of the abscesses escape detec- 
tion in the living. One may conclude, then, that abscess may be 
expected as a more or less serious complication in 25 per ccut. of 
all cases of Pott's disease, and in at least half of those in which 
the lower region of the spine is involved. The greater frequency 
here is explained by the large size and less resistant structure of 
the vertebral bodies, as compared with those of the upper regions. 

The tuberculous abscess is separated from the neighboring 
parts by a limiting wall varying in thickness according to its 
age, the outer layers of which are of fibrous and cellular tissue, 
the inner of granulation tissue covered with yellowish-gray or 
pinkish-gray, necrotic membrane, which is easily separated from 
the underlying parts. The fluid of the abscess is usually of a 
whitish or whey-like color, composed of serum, leucocytes, and 
emulsified caseous material and fibrin. Floating in it are large 
masses of cheesy, necrotic tissue and sometimes minute fragments 
of bone, which settle to the bottom of the glass if the fluid is 
allowed to stand. Certain of the smaller quiescent abscesses 
contain only this whitish semi-solid material. The fluid of 
abscesses in process of resolution is often clear, like serum, but 
if secondary infection has taken place the pus is of a greenish- 
yellow color, and is of uniform consistency. At any stage of its 
progress the abscess may become stationary and its contents may 
be absorbed, in fact, such an outcome is not unusual. The fluid 
of the abscess is usually sterile, and secondary infection, before a 
communication with the exterior of the body is established, is 
comparatively uncommon. 

It has been claimed that abscess formation is always the result 
of infection with pyogenic germs, but this may be doubted, since 
the ordinary tuberculous abscess may be sterile or at mos1 contain 
but a few tubercle bacilli. It is certain, on the other hand, that 
the formation and increase of the abscess is favored by irritation 
and injury, and that the most effective treatment of this compli- 
cation is to support the diseased spine and to relieve it from 
overstrain. 

Abscess is a symptom of disease, and it is in some degr 



1 . >,; ORTHOPEDIC SURGERY. 

evidenoe of it- character. If it appears early and increases in 
apidly, it 11-11:1 1 In- indicates a destructive and rapidly advanc- 
ing process, or infection from without. On the other hand, the 
slowly enlarging or quiescent abscess has Imt little significance. 

In many instances the abscess causes no symptoms whatever, 
<>r it may be :i source of inconvenience simply because of its size 
or situation. In other cases a period of malaise or discomfort or 
pain is followed and explained by the appearance of an abscess, 
I nit whether the symptoms are caused by the tension of the 
ss or by a more acute phase of the disease itself is not always 
clear. 

Large abscesses that are increasing in size and approaching the 
Burface are usually accompanied by pain and by elevation of 
temperature. This indicates, probably, a slight degree of second- 
ary infection, but the ordinary deep abscess appears to. have no 
other effect than to add, doubtless, to the susceptibility of the 
patient. 

The Course and Peculiarities of Abscess in the Different Regions 
of the Spine. The tuberculous abscess may remain as a small 
collection of fluid in the neighborhood of the diseased area. As 
a rule, however, it slowly increases in size, and under the in- 
fluences of the force of gravity and the tension of its contents it 
finds it- way down the spine or toward the exterior of the body, 
following the path of least resistance. The abscesses which have 
passed below the diaphragm or which have originated below this 
point may follow various paths. Some enter the sheath of the 
psoas muscle, and, finally, make their appearance on the inner 
aspecl of the thigh, psoas abscess. Others perforate the sheath of 
tl"- quadratus Lumborum muscle and form a lumbar abscess, 
projecting between the twelfth rib and the crest of the ilium at 
the triangle of IVtit. Those abscesses that escape from the fascia 
of the psoas muscle or that pass downward on the surface of the 
iliac fascia, the so-called iliac abscesses, may appear as a tumor 
the outer extremity of Poupart's ligament at the junction of 
the transversalia and iliac fasciae, or the fluid may follow the 
course of the iliac artery to the thigh, or, escaping from the 
greater sacrosciatic foramen, form a gluteal abscess. 

[liac or psoas abscess is most often confined to one side, but it 

may be bilateral, the two sacs communicating with one another 

by a larger or smaller channel. In the thoracic region the abscess 

may remain indefinitely in the posterior mediastinum, where, if 

presence maybe demonstrated by an area of dulness 



TUBERCULOUS DISEASE OF THE SPIXE. 



107 



extending toward the lateral region of the thorax, or it may per- 
forate the intercostal muscles and appear on the posterior or lateral 
aspect of the chest, or it may pass downward through the aortic 
opening in the diaphragm and become an iliac abscess. 

Abscess caused by disease of the oeeipito-a.void region may 
force its way forward between the recti muscles and appear behind 
the pharynx as the retropharyngeal abscess, or the fluid may take 



Fig. 66. 




Bilateral lumbar abscess. 



the opposite direction and distend the suboccipital triangle and 
then pass forward to the region of the mastoid process. In other 
instances the abscess may dissect its way about the base of the 
skull or pass upward through the foramen magnum or downward 
into the spinal canal. 

Abscesses from the middle cerviccU region usually pass outward 
between the scaleni and longus colli muscles to the into 
between the trapezius and 9ternomastoid, perforating the -km 
about the middle of the lateral a~|»--r-t of the neck near tie- anterior 
border of the latter muscle. 



LOg ORTHOPEDIC 8URQEM V. 

These aw the paths usually followed by the tuberculous fluid, 
I. ut occasionally it may enter the spinal canal or break into the 
pleural cavity or lung or intestine or by the side of the rectum or 

rU.'W | 

Treatment of Abscess. Abscess is by far the most troublesome 
and dangerous complication of Pott's disease. It may interfere 
with proper mechanical treatment, and it is often a cause of 
permanent as well as temporary deformity, especially in the lower 
region of the spine, as has been stated. It prolongs the course 
of the disease by extending its boundaries, and, although it is 
uol often a direct cause of death, yet many patients die because 
of the exhaustion of long-continued suppuration that may follow 

- radary infection, and of the amyloid degeneration that may 

finally result. 

A large abscess is always a source of danger because of the 
p issibility <»f secondary infection of its contents before it finds 
an nutlet, and because of the probability of infection when a com- 
munication with the exterior has been established. Abscess is, 
however, a symptom and result of disease, and in properly 
! cases it i-, a- a rule, a complication of comparatively 
slight consequence. If it is not present when treatment is begun, 
one may hope to prevent it by effective protection of the spine, 
and If it i- present, this protection should be all the more rigidly 
enforced. An abscess often exists for months before its presence 
i- detected, and after its discovery it may remain quiescent for a 
long time, and finally disappear. 

In .1 very large proportion of cases the abscess causes no symp- 
toms, hut slowly finds its way to the surface of the body. Mean- 
while it may he assumed that the disease of the spine, of which 
bscess is a result, is in process of cure; so that when the 
fluid finds an outlet the source of supply will be shut off, and 
thus th«- patient i- spared the danger and discomfort of discharg- 
it so often persist after early operation. 

Th. so-called radical treatment of the abscess of spinal disease 
is unsatisfactory, not because this is different in character from 
other tuberculous abscesses, but because it is, as a rule, impossible 
t" remove the disease of which the abscess is a symptom; and 
incomplete or ineffective surgical operations should be avoided. 
\- l1 "' abscess i- a symptom of disease, so, as a rule, its 
treatment should 1><- symptomatic. The retropharyngeal abscess 
demands prompt evacuation, because it is likely to obstruct 
breathing and Bwallowing, because its sudden rupture may cause 



TUBERCULOUS DISEASE OF THE SPIXE. 1Q9 

death, and because an abscess in such close proximity to the vital 
centres is always a source of danger. In cases of emergency the 
abscess may be evacuated by an iucision in the middle line of the 
pharynx, but preferably the openiug should be from the exterior. 
An incision is made along the posterior aspect of the steruomas- 
toid muscle in its upper third. The abscess tumor is easily 
reached by careful dissection, and drainage is established which 
has evident advantages over that into the throat. 

Abscesses from the middle cervical region usually point in the 
lateral region of the neck aud cause but little inconvenience. 
Abscesses in the upper thoracic region may, in rare instances, 
cause dangerous pressure on the trachea or lungs, as shown by 
spasmodic attacks of inspiratory dyspnoea, " asthmatic attacks." 
In some instances an area of dulness near the seat of disease 
demonstrates the position of the abscess, but if it lies in the 
median line it cannot be detected either by auscultation or percus- 
sion. If the inspiratory dyspnoea is well marked the symptom 
may be fairly attributed to this cause, and if the spasmodic 
attacks are frequent and severe the operation of aostotransversectomy 
is indicated. An incision is made, preferably on the right side, 
to expose the articulation between the transverse process and the 
rib, aod one or more of the joints are resected ; the finger is then 
inserted and passed along the surface of the adjacent vertebral 
body until the abscess sac is reached. This is usually directly in 
front of the spine at or about the fifth dorsal vertebra. After 
incision a large drainage-tube should be inserted (Fig. 9). 

In the lower region of the spine intervention may be necessary 
because there is evidence of secondary infection. In this event if 
the abscess distends the lumbar region or forms a sac on either 
side of the spine, an opening in the loin on one or both sides of 
the spine is necessary. This is made as in operations on the 
kidney, by an incision on the outer side of the erector spina 
muscle between the last rib and the crest of the ilium. In cer- 
tain cases it is possible to expose the spine and to remove frag- 
ments of necrosed bone along with the contents of the absa 
As a rule, the complete removal of the lining membrane of the 
abscess is not practicable, and one must be content to evacuate 
the solid and semi-solid contents by flushing with hot water, 
together with as much of the abscess membrane aa may be 
removed by swabbing with gauze. The most important point m 
the operation is to provide efficient and complete drainage of the 
cavity. Two or more counter-openings are usually accessary 



1 [(J ORTHOPEDIC SURGERY. 

when til.- lumbar incision has been made, one just in front of the 
anterior Buperior spine and another in the thigh, if the abscess is 
of the psoas variety. Long drainage-tubes are inserted, and 
Bhould remain until a proper channel for the escape of pus has 
been established. 

When the abscess is of one side only, not extending into the 
thigh, and when the symptoms do not indicate infection, but 
when its evacuation seems advisable because of its size and ten- 
sion, it may be opened by an anterior incision below Poupart's 
ligamenl just to the inner side of the sartorius muscle. After 
copious injections of hot water a drainage-tube may be inserted 
long enough to reach to the seat of disease if it be of the lumbar 
region. 

I n after-treatment irrigation is not often required ; the dressing 
Bhould be of dry sterile gauze, and great attention should be paid 
in absolute cleanliness and to effective drainage. As soon as is 
possible, if the discharge has become slight and if the spine can 
I..- properly supported, the patient is allowed to walk about and 
to go into the open air. In ordinary cases a slight discharge 
will persist for several months or longer, depending on the con- 
dition of the disease; if, however, it be quiescent or cured the 
sinus will close promptly. 

In the symptomatic treatment of abscess, aspiration is some- 
times of service, for by T this means it may be prevented from 
mcreasing in size; and if the disease is quiescent, the cure of the 
abscess may follow the removal of its contents which allows the 
collapse of its walls. When aspiration is employed it should be 
repeated systematically as often as the abscess cavity refills. 
After each evacuation pressure should be applied to favor the 
adhesion of the apposed walls. 

^ ben the contents are of such a nature that aspiration is 
ineffective, an incision may be made, through which the semi- 
solid substance may be removed by vigorous flushing with hot 
wat<r. The opening is then closed by several layers of sutures, 
and pressure is applied with the aim of obtaining primary union. 
This method is sometimes successful, but usually a sinus forms 
at the point of incision. 

I mil recently the injection of antituberoulous remedies into the 
was in favor. This is probably of value in diminish- 
the infective quality of the contents, perhaps, also, in les- 
sening the danger of mixed infection and in stimulating the 
itive pro Clinically, it appears to have little direct 



TUBERCULOUS DISEASE OF THE SPIXE. m 

effect upon the course of the tuberculous disease. An emulsion 
of iodoform in sterilized oil or glycerin (10 to 20 per cent.), in 
doses of from 4 to 30 grammes, is injected at intervals of from 
two to four weeks, with or without previous evacuation of the 
contents ; the amount and the frequency of the injection depend- 
ing upon the age of the patient and upon the effect of the treat- 
ment. If used with caution as to asepsis, and to the toleration of 
the patient for iodoform, no harm will follow, even if the treat- 
ment proves to be of little practical value. 

AVhen an abscess approaches the surface the skin becomes red 
and thin, and there is usually some local tenderness and pain. 
Whenever spontaneous evacuation of the abscess is probable the 
mother should be instructed as to the necessity of absolute cleanli- 
ness, and the proper dressings should be provided. After the 
abscess has broken the patient should remain in bed for several 
days, or until the discharge has become small in amount. 

In the symptomatic treatment of the abscesses of Pott's disease 
one may conclude, then, that operation will be indicated in the 
treatment of the retropharyngeal abscess and in the rare instances 
when dangerous pressure is exerted by an abscess in the posterior 
mediastinum. It is indicated, of course, when there is evidence 
of mixed infection or when the rapidly increasing abscess causes 
discomfort or interferes with effective support. It is usually 
indicated when the abscess is of large size if proper care can be 
provided. The operative treatment is practically free from 
danger if cleanliness and efficient drainage can be assured. 
Aspiration is free from danger ; it is often of service in prevent- 
ing the enlargement of the abscess, and it may hasten its absorp- 
tion. An incision which allows for the evacuation of the solid 
material, followed by immediate closure of the wound, is in many 
instances the operation of selection. 

Paralysis from Pott's Disease. 

The tuberculous process in the vetebral bodies may extend 
backward, and breaking through the posterior ligament it may 
enter the epidural space and press upon the spinal cord ; then 
follows paresis or paralysis of the parts below the constriction. 

The calibre of the spinal canal La not usually lessened by the 
characteristic angular distortion of the back, although the wreighl 
and forward inclination of the trunk may force the softened 
tissues backward against the cord and thus increase the direct 



I [2 ORTHOPEDIC SUBOEBY. 

pressure ; in fact, paralysis is much more often associated with 
;i Blight or moderate kyphosis than with extreme deformity. 

In rare instances the pressure may he due to a fragment of 
necrosed bone or to solidification of the tissues in and about the 
canal during the process of repair. It may be caused, in part, 
at least, by the pressure of a neighboring abscess, but it is 
usually the result of the Blow advance of the tuberculous granu- 
lation tissue. When this has forced an entrance into the spinal 
canal it Bets up a resistant inflammatory thickening of the cover- 
ings of the cord, first a peripachymeningitis and then a pachy- 
meningitis. In addition to the direct pressure, there may be an 
interference with the blood supply and the lymphatic circulation, 
with resulting local (edema of the cord. An increase in the 
interstitial connective tissue of its substance and a corresponding 
atrophy of the nervous elements may follow, and as a sequence 
an ascending and descending degeneration that, in prolonged 
may terminate in partial or complete sclerosis. The dura 
mater i- a resistant structure, and direct destruction of the cord 
by the tuberculous disease is rare. In fact, as a rule, but little 
permanent damage results, even from long-continued pressure 
and paralysis, for the cord seems in these cases to possess the 
power <>f repair and regeneration to a remarkable degree. 

Frequency. In 10 TO cases of Pott's disease recorded at the 
New York Orthopedic Dispensary, paralysis occurred in 218, 1 
and in \ I"* cases in the private practice of Dr. C. F. Taylor 2 59 
of paralysis were observed. Thus, in a total of 2015 cases 
of Pott's disease there were 270 cases of paralysis, or 13.7 per 
cent 

This proportion i- much larger than the normal, however, for 
many <»f the patient- were taken to the specialist or to the special 
hospital because of the paralysis, as in 40 of Taylor's and in 133 
<>f the dispensary cases. If these be excluded, the percentage 
of paralysis occurring in those actually under treatment is reduced 
'" 5.6 per cent This percentage corresponds very closely to 
that «.f Dollinger, 8 viz. : II cases of paralysis in 700 cases of 
under treatment (5.8 per cent.), and it may be 
accepted as representing the average liability to paralysis among 
who have received treatment for Pott's disease, the per- 
centage being much higher in neglected eases. 

' orthopedic Association, 1891, vol. iii. p. 209. 
rett. New York Medical Record, June 19, 1896. 



TUBEBCCLOrS DISEASE OF THE SPIXE. 



113 



The Liability to Paralysis in Disease of the Different Regions of 
the Spine. The liability to paralysis is very much greater in dis- 
ease of certain regions of the spine than in others. 

Thus, 105 of the 209 cases in Myers' list, in which the situa- 
tion of the disease was recorded, complicated disease of the dorsal 
region above the eighth vertebra. Of the remainder, in 1»> the 
disease was of the cervical region ; in 12 of the cervicodorsal, and 
in 59 of the lower dorsal and dorsolumbar regions. 

Thirty-seven of Taylor's 59 cases were caused by disease of the 
dorsal region ; 8 occurred iu the cervical and cervicodorsal, and 
11 in the dorsolumbar and lumbar regions. 

Twenty-six of the total of 41 cases recorded by Bollinger were 
caused by disease of the third to the seventh dorsal vertebra?, 
inclusive, or about 23 per cent, of the cases in which this region 
was involved. 

Fig. 67. 




Pott's paraplegia before the stage of deformity. The apparatus used in the treatment 
of this case is shown in Fig. 51. 

Of 132 cases of paraplegia reported by Gibney 1 not one coin- 
plicated disease of the lumbar region; nearly all were caused by 
compression in the middle or upper dorsal segment. 

These statistics show that the upper and middle dorsal section 
is the point of greatest liability to paralysis — a fart thai is 
explained possibly by the smaller size of the canal at this point, 
and by the difficulty in assuring complete fixation at tin- -cut <>f 
disease. It may be estimated that in 15 per cent, of tin 
of Pott'- disease of this region paralysis will appear before cure 
is established. 

Time of Onset. In exceptional cases the paralysis may pre- 
cede deformity, and it may be the first Bymptom that ;r 



Journal of Nervous and Mental Disease, .Januar; 
8 



H j ORTHOPEDIC SURGERY, 

attention to the disease. In 1 I of 7 1 cases reported by Gibney 
the paralysis was present when the bone disease was recognized, 
but it is probable that the primary disease had existed for 
Beveral months before the appearance of the paralysis. Usually 
a comparatively laic symptom, appearing after the stage of 
deformity and more often from six to twelve months after the 
dtion of the disease, but its appearance may be deferred 
until long after apparent cure. 

Duration. In exceptional cases the paralysis appears to be 
caused -imply by disturbance of the circulation of the cord, due 
possibly to the pressure of the superincumbent weight upon the 
softened and diseased tissues, as it disappears almost immediately 
when the spine is straightened and supported. Usually the 
paralysis persists for several months, not infrequently it lasts a 
year, and partial or even complete recovery is possible after a 
much Longer time. Recovery from the paralysis depends upon 
ih. course of the disease of which it is a symptom, upon the 
absorption and organization of the tuberculous granulations that 
press upon the cord, and upon the regenerative changes in its 
structure, if it has been implicated in the disease. 

Symptoms of Pott's Paraplegia. The most marked effect of 
the pressure on the cord is the interference with its conductivity; 
thus, the reflex centres situated below the point of constriction, 
relieved from the inhibition of the brain, become overactive, while 
voluntary motion of the parts below the constriction is difficult 
<>r impossible. The pressure of the diseased products is more 
directly upon the anterolateral columns, so that motion is much 
more often primarily affected than is sensation. 

The early symptoms of Pott's paraplegia, as noticed by the 
patient or his friends, are weakness, awkwardness, and a stum- 
bling, shambling gait. The symptoms usually increase rapidly 
until paralysis of motion is complete. At this stage the patella 
tendon reflex is increased, and ankle-clonus is often present. As 
a rule, both liml>> are affected in equal degree, but occasionally 
paralysis of one may precede that of the other, and in the stage 
of recovery power may return more rapidly on one side than on 
the other. The limbs in the early stage of the paralysis may 
appear limp and powerless, but when the patient is moved or 
when the reflexes are stimulated the peculiar spastic rigidity or 
Btiffnesa appears. 

\- a rule, the stiffness increases with the duration of the dis- 
and spastic contractions are often present; thus, the thighs 



TUBERCULOUS DISEASE OF THE SPINE. 115 

may be approximated, the knees flexed, and the feet extended. 
Persistent contractions indicate, as a rule, permanent damage to 
the cord, and in such cases complete recovery is infrequent. 

Sensation is not affected ordinarily, but in the more severe or 
prolonged cases it may be impaired or lost. Sensation was 
retained throughout in 24 of the 40 cases reported by Shaffer. 

In the cases of partial paralysis control of the bladder may be 
retained, but usually there is incontinence. As the bladder fills 
the reflex centre is excited, and it empties itself. The control of 
the sphincter ani is less often or less noticeably affected. 

As the paralysis is the result in many instances of active or of 
advancing disease, its onset may be preceded by discomfort or 
pain. Thus, noticeable discomfort attended by an exaggeration 
of the patella tendon reflex may be considered as an indication 
for enforced rest of the individual, although increased activity of 
the reflexes is not uncommon during the more active stage of the 
disease without apparent involvement of the spinal cord. "When 
paralysis occurs in patients who are under treatment for Pott's 
disease the onset is not attended, as a rule, by noticeable or 
unusual pain ; nor is pain usually complained of after the paralysis 
has developed. 

The extent of the paralysis depends upon the situation of the 
disease. In exceptional cases, in which the cervical cord is im- 
plicated, both the arms and legs may be paralyzed ; this occurred 
in seven of the cases reported by Myers. As a rule, however, 
the paralysis is a complication of disease of the dorsal region, 
above the reflex centres in the lumbar enlargement of the cord, 
but below the nerve supply of the upper extremities. If the 
disease were at a lower point, for example, in the dorsolumbar 
section, so that these reflex centres themselves were directly im- 
plicated, then reflex activity would not be increased, and inter- 
mittent incontinence would be replaced by constant dribbling of 
urine. If the cauda equina alone were implicated in disease of 
the lumbosacral region, the symptoms would be those of neuritis, 
pain, numbness, and weakness in the area supplied by the affected 
nerves. Such weakness may be present in the upper extremities 
when the disease is in the neighborhood of the origin of the 
brachial plexus, while in the lower limbs the characteristic spastic 
condition is evident. 

The nutrition of the limbs is not as a rule greatly affected, 
nor do the contractions become permanent; but when the par- 
alysis is prolonged, and when sensation is lost, the muscles 



I |,; ORTHOPEDIC SURGERY. 

the circulation La impaired, and fixed distortions usually appear. 
Even in the more prolonged and severe forms of paralysis, 
occurring in childhood, bedsores are rarely seen. 

Prognosis. In properly treated cases the prognosis is very 
favorable, as is illustrated by the final results of 47 of the 59 
cases of paraplegia in Taylor's practice. Of these 39 recovered 
completely, 5 died of intercurrent disease while apparently recov- 
ering, and in 3 the recovery was partial. 

Of the hospital cases recorded by Myers, 3 per cent, died of 
intercurrent disease. The final results could be ascertained in 
l»nt 55 per cent, of the patients who remained under treatment. 
All of these recovered. 

( )f 7 I cases of paraplegia treated by Gibney 1 45 were cured, 
12 improved, 8 unimproved, and 9 died. Thus, 77 per cent. 
\\ ere cured or Improved. In a similar series of 40 cases reported 
by Shaffer 80 per cent, were cured and but 10 per cent, of the 
remainder were considered as hopeless cases. 

In a total of 975 eases "abandoned to medical treatment" 
collected from various sources by Rozoy, 2 there were 429 cures. 
( )f the remainder 16 were improved; 130 were unimproved, and 
there were 244 deaths. The contrast in the results reported 
would appear to show the advantage of thorough mechanical 
treatment. 

Recurrence of paralysis after recovery is not infrequent; in 
1 B cases such recurrences from one to four times are recorded by 
Myers, and -even successive attacks of paralysis were observed 
m b patient under treatment at the Hospital for Euptured and 
< 'rippled. 

The relapses are due apparently to the renewed activity of 
tie disease, and iii many instances this may be explained by the 
neglect of protective treatment. 

Treatment. The treatment of the paralysis is included in the 
treatment of the disease of which it is a symptom, except that 
even greater care should be exercised to assure fixation of the 
spine. 

Res! in the position of hyperextension on the stretcher frame 
ifl indicated. Direct traction by the weight and pulley should 
be used if the disease is in the upper dorsal or cervical regions. 
For bedridden patients a convenient method of assuring extension' 
of the spine in connection with head traction is to suspend the 
trunk on a Bling of canvas drawn transversely beneath the seat 

2 Mai. de Pott, Paris, 1901. 



TUBERCULOUS DISEASE OF THE SPINE. 117 

of disease and attached to bars on the sides of the bed after the 
Rauchfuss method. The back brace or the plaster jacket assures 
additional fixation, and such support should be employed when- 
ever practicable. If, however, the brace has been worn as an 
ambulatory support, its shape must be modified to accommodate 
the change in the outline of the spine, induced by recumbencv 
and extension. 

Manipulation or massage of the limbs is contraindicated because 
ir stimulates the reflex centres. If constant contractions of the 
muscles are present, the deformity may be reduced by traction 
applied in the ordinary manner (Fig. 32), or a fixation brace may 
be worn. The spasmodic contractions are often painful, and if 
the paralysis is complicated by tuberculous joint disease, extension 
and fixation combined may be indicated to relieve the joint from 
the injury of involuntary motion. 

Counterirritation at the seat of disease was by Pott considered 
of the greatest value, and the application of the actual cautery 
from time to time, about the kyphosis, seems in certain cases to 
exert a favorable influence on the underlying disease. 

Electricity, particularly galvanism, has been used, and it is of 
some service in preserving the nutrition of the limbs. Its value 
in a case must be judged by its effect. 

Of the internal remedies the most useful seems to be iodide of 
potassium. It is supposed to act upon the tuberculous granula- 
tion tissue as upon the products of syphilitic disease. A conve- 
nient method of administration is a solution of which one drop 
represents one grain of the drug. This is given in milk or in 
Vichy water, beginning with five drops three times daily and 
increasing the dose a drop each day until the point of toleration 
is reached. 

The first indication of improvement is usually lessening of the 
muscular rigidity ; then the ability to move a toe may be regained, 
after which recovery follows quickly. At this stage massage of 
the limbs may be employed with advantage. The exaggerate id 
reflexes may persist long after recovery ; in fact, a- has been 
-rat<d. r 1 1 i — symptom is not uncommon among patients suffering 
from dorsal Pott's disease who have never been paralyzed. 

The Operative Treatment. The operation of laminectomy was 
at one time in favor, but it has now been practically abandoned, 
as a treatment of routine at least, for the paraplegia of Pott'fi 
disease; because it has been proved that recovery, if somewhat 
long deferred, is the rule without operation, while the direct 



1 is bRTHOPEDIC SURGERY. 

death-rate of the operation is a large one. In 134 cases collected 
l.v Rhein 1 the immediate mortality (those dying within a month 
aft»r the operation) was 36 per cent. 

Lloyd 1 has collected L28 " reliable" cases of Pott's disease in 
which laminectomy was performed. The deaths due directly to 
the operation were 2] (16.45 per cent); subsequent deaths, 36 
28.20 per cent.) ; total deaths, 57 (44.55 per cent.); recoveries, 
37 28 per cent); improved, L6 (1*2.5 per cent.); unimproved, 
l - 14.06 per cent.). 

Laminectomy i< an incomplete operation in the sense that the 
disease of the bone is not removed, and recurrence of paralysis 
and extension of the disease are not infrequent after a successful 
immediate result It should be reserved for those cases in which 
a thorough and prolonged trial of ordinary methods the con- 
dition does not improve. Eighteen months has been suggested 
;i- tin proper time in which to test conservative treatment. The 
operation may be indicated also if the symptoms, in spite of treat- 
ment, increase in severity, and when there is evidence that the 
integrity of the cord is threatened, or when the paralysis is of 
sudden onset, or when displacement of bone or pressure from an 
abscess Beems probable as the exciting cause, although in the 
latter instance the direct evacuation of the abscess by costotrans- 
versectomy, as advocated by Menard, should precede laminectomy. 
I Occasionally the operation is indicated as a forlorn hope in adults 
Buffering from cystitis and bedsores. 

The usual method in operating is as follows: A long incision 
is made parallel to and close by the side of the spinous processes. 
The muscles are drawn to one side, the spinous processes are cut 
through and drawn with the attached muscles to the opposite 
ride. The laminae at the seat of disease are then removed with 
the cutting forceps, exposing the dura mater. The tuberculous 
tissue is usually found upon the front or lateral surfaces of the 
canal, and it- complete removal is often impossible. The shock 
of the operation is often marked, so that it should be as rapid as 
possible, and Loss of blood should be carefully guarded against. 
rule, the wound may be closed without drainage. After the 
operation the spine should be supported by the brace or jacket 
until the disease is cured. 

1" Beveral instances forcible correction of the spine (Calot's 
operation) relieved the pressure on the cord and rapid recovery 

1 WUlard. Journal of Nervous and Mental Disease, May, 1897. 
Lladelphia Medical Journal, February 22, 1902. 



TUBERCULOUS DISEASE OF THE SPINE. 119 

followed. This indicates the importance of assuring overextension 
of the spine whenever it is possible, but this should be attained 
preferably by gradual, postural correction rather than by force. 

Fortunately, the great majority of cases of paraplegia from 
Pott's disease occur in childhood, and, as has been mentioned, 
the complications of later life, bedsores, cystitis, and the like, are 
rarely troublesome. Such paralysis in the adult is more serious 
from every point of view. The principles of treatment are the 
same, but their application is more difficult and the prognosis is 
more doubtful. 

Local Paralysis. In certain cases the extension of the disease 
may involve the nerve roots at their exit from the spine. This 
may occur with or independently of the involvement of the cord. 
The symptoms are those of neuritis in the affected nerves. In 
extremely rare instances the pressure on the cord may cause 
hemiplegia. 

Forcible Correction of the Deformity of Pott's Disease. 
Calot' s Operation. Forcible correction of the deformities of 
the spine was advocated by several of the ancient writers, notably 
by Hippocrates and by Pare, but in modern times, with the better 
understanding of the pathology of Pott's disease, the direct de- 
formity that a patient presented when coming under treatment 
was supposed to be irremediable, since it represented actual 
destruction of bone. 

In 1896 this method of forcible correction of deformity which 
had been revived by Chipault several years before 1 was popu- 
larized by Calot, of Berck sur Mer, 2 who claimed that it was par- 
ticularly adapted to the treatment of the kyphosis of tuberculous 
disease. Originally he advocated the immediate correction of 
such deformity, although of long standing, even if chiselling 
through the anchylosed vertebrae and removal of the spinous 
processes were required. This has been abandoned long since, 
and even the treatment to be described has fallen into practical 
disuse at least in this country. 

At the Eleventh Congress of French Surgeons at Paris in 1 897 
Calot outlined the operation as follows: In the recent casea the 
deformity was corrected by direct manual traction and by pressure 
on the kyphosis. The traction employed was estimated al 
to one hundred and sixty pounds, the pressure at thirty to eighty 
pounds, but in the more resistant type it was well to reduce the 

' Travaux de neurotome Chir., 1896 

-' Archiv prov. de Chir., February, 1897, T. 6, D. 2. 



ORTHOPEDIC SURGERY. 

deformity gradually al several Bittings. Of 204 patients treated 
l,v this method, 2 died within two days and 3 others several 
months after the operation. In 1 case partial paralysis appeared, 
and in another an abscess appeared soon after the procedure. 

Since < blot's original publication hundreds of operations have 
been performed with results not differing essentially from those 
thai he reported. It has been demonstrated that the deformity 
of Pott's disease In more recent oases can be partly or entirely 
corrected by force in one or more sittings with bnt little danger 
to the patient. 1 If the disease is in the progressive stage, and if 
the operation is undertaken before adhesions and contractions 
have formed, the correction will be easy. If the disease is in the 
i of repair, the correction will necessitate forcible separation 
of contracted tissues and the breaking up, it may be, of an actual 
anchylosis. If an abscess is present, whose coverings are adher- 
ent to the surrounding parts, the forcible correction may rupture 
it- walls and allow the escape of the pus into the lung or pleural 
cavity. The more remote dangers are abscess or paralysis due to 
a dire.-t extension of the local process, or general dissemination 
of the tuberculous disease. 

[f the deformity is corrected it is evident that there must be 
an actual separation of the diseased parts; the spine is, as it were, 
straightened on the hinge formed by the articulating surfaces of 
the transverse processes (Fig. 4). This is an attitude favorable to 
repair, since compression and attrition can no longer aggravate the 
destructive process. If paralysis is present, induced in part by 
the compression of the softened tissues at the seat of disease, it 
may be relieved by the correction of the deformity. 

It must be borne in mind, however, that the operation is 

undertaken for the relief of deformity. It is certain that the 

spine can be straightened and that it can be retained for a time in 

orrected position, but it is unlikely that the interval left 

en the upper and Lower segments of the spine will be filled 

d Med. and Surg. Journ., September 20, 1900) have analyzed 
the li - - operation, via. ; 

I and thirty-nine cornet inns were performed by thirty-four operators. Time 
i from a few days ap to three years or more. Of the separate detailed cases in 
;i 86 more than six months. 
"Mm nil causes, 25; ?ai es, 5; general tuberculosis, 4; trauma 

■ on nn<i chloroform, 5; Intercurrent disease, 7. 

> embarrassment, 7 ; pain, 6 ; severe shock, 3. 
mii, 19 : ruptured, 4 ; benefited or absorbed, 6 ; appeared after 

P»rah Operation, 28 ; relieved, 17 ; not relieved, 2 ; made worse, 1. 

in l. 

1 omplete correction, 130 ; incomplete, 94. 
. f in 77 r&<u?* \ No relapse, 20 ; some relapse, 50 ; total relapse, 7. 



TUBEBCULOUS DISEASE OE THE SPIXE. 121 

with new bone, because the capacity for bone formation is in this 
locality very feeble. 

There is, as a rule, an immediate recurrence of a certain amount 
of deformity because of the natural recoil toward the habitual 
posture, and because iu many instances the straightening of the 
spine has been due to an obliteration of secondary curvatures 
rather than to actual separation at the seat of disease. Even if 
the deformity were obliterated, and if the interval between the 
segments were filled with calcified tissue, such bone cannot grow ; 
consequently the irregularity must become more and more marked 
with the growth of the child. In other words, although the 
effect of the destructive disease on the spine may be modified it 
cannot be entirely remedied even by the most successful operation. 

The Selection of Cases for Forcible Correction. The favorable 
cases are those in which the deformity is of comparatively short 
duration, cases in which the adhesions and the accommodative 
changes in the soft parts are not sufficient to offer resistance to 
correction, and in which the internal organs have not been long 
displaced or compressed. "Well-marked deformities of the middle 
and lower dorsal region are especially suitable for the operation. 

The most unfavorable cases are those of fixed deformity, in 
which repair is progressing or is completed, and in which the 
organs and tissues of the body have been changed in shape and 
function to accommodate the new conditions. 

As a rule, deformity of the lumbar and of the cervical regions 
is not sufficient to require forcible correction. 

The presence of an abscess in the posterior mediastinum or 
elsewhere, if it be in the active or progressive stage, should con- 
traindicate the operation. On the other hand, paralysis, which 
ifl most often a complication of disease in the dorsal region, is 
not a contraindication. 

The Operation. As ordinarily performed the patient having 
been prepared as for the application of a plaster jacket is anaes- 
thetized and is then suspended face downward in the horizontal 
position by five assistants, who make moderate steady traction 
upon each extremity and upon the head while the surgeon, stand- 
ing by the side of the patient, gently presses downward directly 
upon the kyphosis, which, in the favorable cases, is gradually 
obliterated, the straightening of the Bpine being accompanied by 
the audible separation of adhesions. 

As a rule, the force required is much less than that -fated by 
Calot. Jones states that a traction force of aearly six hundred 



^_ , :. , 



lllllll 



ORTHOPEDIC SURGERY. 



ii. la is required to dislocate the neck of a child two and one- 
half years of age; thai five men pulling in the manner above 
described, with a force thai soon tires, rarely exceed a traction 
fon t* one hundred and Beventy-five pounds. 

If the correction is to be completed at the first attempt the 
spine is overextended, and while it is held in this attitude a 
piaster jacket is applied. If the disease is of the middle of the 
back, the head need nol be included, but it is better to fix and 
draw the shoulders backward by including them in the plaster. 
Great care should be taken to prevent excoriations. Very long, 
thick, wide pads should be placed on either side of the spinous 
processes j the iliac crests and other prominences should be pro- 
tected, and a so-called dinner pad should be inserted below the 
Sternum, which may, when removed, allow additional room for 
respiration. This is of great importance if the patient has not 
worn a plaster jacket before the operation. If the disease is of 
the upper dorsal region, the head must be included in the ban- 
da-- •. ( Jalot suspends the anesthetized patient as in the ordinary 
manner for applying a jacket; other surgeons suspend the patient 
with the head downward during the application of this part of 
the bandage, but with a little care the head support may be 
applied with the patient in the horizontal position. 

Tic hair should be cut closely, and protected from the plaster 
by a well-fitting skull cap. The bandage is then continued over 
the head and neck as in the illustration (Fig. 59). A strip of 
malleable Bteel, bent to fit the occiput, may be incorporated in 
the bandage to give it sufficient strength. 

Many surgeons employ other supports than the plaster. One 
of the best forms of apparatus is the double Thomas brace used 
by Jones. The stretcher frame may be used with the plaster 
jacket to assure recumbency. 

In properly selected cases there is little shock after the opera- 
tion, but if the change in the contour of the spine has been con- 
siderable, respiration may be somewhat embarrassed by the 
plaster jacket In Buch cases it must be split through the front 
and separated, [n all cases it is well to cut through the plaster 
at point- where din-et pressure is likely to be exerted, in order 
ml against excoriations. 

Lb a rule, the operation should he followed by prolonged rest 
on th.- back, three to sis mouths or longer, to allow for adapta- 
tion to the new position and for consolidation. 

\~ has been stated, there is a marked tendency toward recur- 



TUBERCULOUS DISEASE OF THE SPINE. 123 

rence of deformity. On this account some surgeons advocate 
wiring the spinous processes to one another as originally sug- 
gested by Hadra and practised by Chipault. The operation is a 
simple one, but its efficacy is more than doubtful. 

In cases in which the deformity is of the resistant type it is 
well to divide the rectification into several sittings at intervals 
of a week or more. In many instances anaesthesia is not required 
after the first operation ; for traction and even the forcible press- 
ure at the seat of disease do not appear to cause particular dis- 
comfort. 

Gradual Correction of Deformity. Corrective force may be 
applied also by methods that do not deserve the name operation. 
For example, a certain amount of traction and pressure may be 
employed with advantage during the application of the plaster 
jacket in the ordinary manner if the cases are properly selected, 
and the effect of posture in correcting deformity is illustrated by 
the use of the stretcher frame. 

An efficacious method of gradual or non-violent correction is 
that employed by Goldthwait 1 by horizontal traction and lever- 
age. This method is described by him as follows : 

" The apparatus which has been used consists of a strong gas- 
pipe frame, six feet long by two feet wide. Suspended from this 
is a bar (a), in the centre of which is a vertical rod (b), forked at 
the top and long enough to reach to the level of the frame. This 
crossbar is simply suspended from the frame so that its posit inn 
can be changed as desired. Below this is another crossbar (c), 
which rests on the frame and can also be adjusted as to position. 
Upon this latter piece (c) and upon the fork of the rod (6) rest 
two malleable steel bars (d), about eighteen inches long. These 
rest in grooves one inch apart, and should be bent to partly con- 
form with the lumbar curve of the spine, after which they are 
heavily padded with felt and the patient laid upon them. The 
upper end of the bars (d) should just rest upon the fork, not 
projecting over, and when the patient is in position the rod should 
be one inch above the apex of the deformity. The buttocks 
upon the crossbar (c), and the legs are supported by one or more 
heavy webbing -traps which can be tightened or Loosened ;it will. 
Xo support whatever is given the upper part of the body, except 
that the head is steadied by the surgeon with the hand until a 
satisfactory amount of correction has been accomplished, and then 

Transactions American Orthopedic Association, vol. xi. p 



r_'i 



ORTHOPEDIC SURGERY. 



a -imp similar to those used below gives the support so that the 
operator's hand is free. If traction is desirable, it can be applied 
by means of a windlass, which is attached to each end of the 
frame. Fhis makes it possible to obtain much more definite and 
steady traction than would be possible with assistants, but its use 
has aol been found necessary in the majority of the cases, simple 
overextension of the spine accomplishing the same results. 

" When the maximum overextension that is desirable is obtained, 
the strap under the head is fastened and the patient allowed to 
lie In this position while the jacket is applied. In applying this 
the iliac crests Bhould be generously padded with heavy felt, and 
a similar pad Bhould be placed over the upper part of the sternum, 



Fig. 68. 




The planter jacket applied in supine posture by means of the Metzger-Goldthwait apparatus. 

w tii;ir tm> jackel can be carried high up to prevent the upper 
part of the body with the -boulders from drooping forward. In 
the cases with disease in the upper dorsal region the jacket should 
be moulded about the anterior part of the neck so that erect posi- 
tion of the head is necessary. The forked rod (b) is easily 
avoided by a few figure-of-eight turns of the bandage, so that 
when the plaster has 9e1 the patient can easily be lifted off, and 
as the rod b) should be placed one inch above the apex of the 
deformity this weak spot in the jacket is not objectionable. 

« When the patient is taken off the frame the two rods (d) are 
slipped out fn.m below, leaving the padding in place. 

"Asa matter of experience it has been found necessary to prac- 



TUBERCULOUS DISEASE OF THE SPIXE. 125 

tically always cut a small window over the point of greatest 
deformity, as otherwise when the body settles down, as is inevi- 
table, a slough will form even though a liberal amount of padding 
has been used. This procedure is repeated from time to time 
until the best possible attitude has been obtained." 

This method, originally devised as a modification of the Calot 
method of forcible correction of defomity, is now employed in 
the routine application of the plaster jacket. For this purpose 
Goldthwait uses a portable frame, as shown in the illustration 
(Fig. 69). 

The appliances shown on page 89, in which the force of gravity 
is utilized to straighten the spine, are now more commonly used 
for the application of the jacket in the recumbent posture. 

Fig. 69. 




Goldthwait's portable frame for applying the plaster jacket. 

It may be stated of forcible correction of the spine (Calot's 
operation), that it is in no sense curative ; that although it lias 
been proved that the back can be straightened, in many instances 
with ease and in most cases with but little danger, yet the reten- 
tion of the spine in the corrected position is difficult, and a certain 
immediate recoil toward deformity is the rule. Even if the 
interval between the two segments be filled with new bone, the 
growth of the spine at this point being checked, an increase of 
the irregularity with advancing year- may be expected. In fact, 
correction of deformity is in no sense a substitute for preven- 
tion. 

The operation in its original form should be reserved, in the 
writer's opinion, for case- in which the deformity is sharply 
angular, -bowing that the destructive process is limited in its 
extent. If correction is attained, horizontal fixation should be 



[26 ORTHOPEDIC SURQER V. 

continued, it' possible, for many months as an essential part of the 
treatment. 

The final judgment oannol be passed upon this procedure at 
the present time. It has rapidly lost favor recently, partly 
because of recurrence of deformity, and partly because experience 
has Bhown thai the same degree of rectification may be attained 
1»\ milder methods. 

The Duration of the Treatment of Pott's Disease. The duration 
of the treatment must depend upon the extent and severity of the 
disease. It may be divided into two periods: one during which 
the dis< tase is active, when absolute fixation is indicated, and a 
of recovery, during which supervision is required. During 
the first stage the destructive process may increase the absolute 
deformity ; during the later period of weakness the distortion 
may increase, simply because of the general inclination toward 
deformity and because of the atrophy of the supporting muscles. 

Tuberculosis of the >|>ine is slow in its progress, and recovery 
is «»ftcn insecure. The course of the disease is shortest in the 
cervical region, but even here two years of brace treatment will 
probably be required, and in the lower region double this time, 
even in the milder type of cases. Active treatment should be 
continued a- long as there is evidence of disease. The absence 
of actual pain and discomfort is of little value in determining the 
absolute cure if braces have been employed. The absence of 
muscular spasm is more significant, since it usually persists as 
long a- the disease Is active. The presence of pain on passive 
motion or muscular contraction or abscess would, of course, indi- 
cate the necessity of further treatment. 

Direct palpation i< of some value in determining the condition 
of the affected part During the progressive stage, careful, deep 
ore over the spinous processes may show greater mobility of 
those involved in the disease. During the stage of repair and 
consolidation the mobility \a replaced by rigidity. The appear- 
and of the kyphosis has some significance. In the early stage of 
the disease it- area is not clearly defined, but when consolidation 
has taken place it- extent Is shown by the rigid vertebrae, which 
stand oul separated from the remainder of the spine by a well- 
marked sulcus, which i- much deeper below than above the 
kyphosis. 

Even when the disease appears to be cured, removal of siqiport 
should be gradual and tentative; tin; jacket should be replaced 
by tic oor» t, or the brace by a lighter appliance; then support 



TUBERCULOUS DISEASE OF THE SPIXE. 127 

may be removed at night, later for part of the day, and at last, 
after many months, it may be discarded. Then may follow 
massage of the atrophied muscles of the trunk and gentle exercise. 

Such careful supervision must be continued for a much longer 
time if the best ultimate result is to be attained, for, as has been 
mentioned, one should guard against the secondary distortions, 
which may be due simply to weakness and to the unfavorable 
mechanical conditions induced by the primary deformity. If 
curvatures of the spine are so common among those whose backs 
may be supposed to be fairly normal, how much more likely is 
such secondary deformity to result when the back has been weak- 
ened by disease and by long disuse of the muscles. 

This secondary increase of deformity is not so much to be 
feared after the cure of the disease in the lumbar region, because 
of the favorable attitude of erectness, nor is it likely to be marked 
after cure in the cervical region of the spine ; but in disease of 
the upper and middle dorsal region support must be continued 
long after the disease is cured, and supervision must be exercised 
until after the period of adolescence, if the increase of deformity 
is to be prevented. 

Recurrence of Disease and Later Effects of Deformity. 
The disease may recur after an interval of many years of apparent 
cure, and such recurrences are sometimes accompanied by the 
formation of an abscess or by paralysis. 

If recovery from Pott's disease has been complete, and if de- 
formity has been prevented, the condition of the patient is to all 
iutents normal, but if the course of the disease has been prolonged 
and if the deformity is great his condition is abnormal; he is 
unfitted for ordinary occupations, and comparative comfort is 
assured only by constant care. Such individuals are likely to 
suffer from neuralgic pain about the weakened spine on overexer- 
tion or whenever the general condition is depressed from any 
cause. In such cases the use of some form of light corset adds 
to the comfort of the patient. 

In certain instances pain localized in the lateral region of the 
trunk may be caused by compression of an Intercostal nerve, or 
it may be due to compression of the tissues between the last rib 
and the chin. In several cases of this character, reported by 
Goldthwait, resection of a portion of a rib at the seat of pain 
relieved the discomfort. 

Secondary Deformities. While the patient 18 under treatment 
for Pott's disease one should be on the alert to prevent other 



1 28 ORTHOPEDIC SUBOEB Y. 

deformities that may follow the general weakness and restriction 
of normal functions. One of these is the weak foot, sometimes 
called weak ankle or flat toot, and with it is often associated a 
moderate degree of knock-knee. This may be prevented by the 
use of a shoe of proper shape, of which the heel and sole are 
thickened Blightly on the inner side. 

Recapitulation. Fixation on the stretcher frame is the treat- 
ment o( choice in Infancy and early childhood, without regard to 
the situation of the disease. Ambulatory treatment is the treat- 
ment of -election in later childhood, adolescence, and adult life. 

Ambulatory treatment must always supplement that by recum- 
bency, and in the great majority of cases it is the treatment of 
ssity and routine. Its efficiency will depend, in great meas- 
ure, upon the careful regulation of the strain which the erect 
posture and the activity of the patient throws upon the weakened 
spine. 

( M the relative merits of the supports that have been described 
it may be stated that the plaster jacket has the great advantage 
of cheapness; it- use places the treatment in the hands of the 
surgeon, and in the middle region of the spine it is equal to, and 
may even be superior to, the brace. The laced corset is not 
equal as a suppoii to the solid jacket. 

The hack brace has a wider range of adaptability than the 
jacket It- disadvantages are the original expense, the difficulty 
of accurate adjustment, and the fact that it can be removed by 
the parents, who are inclined to neglect medical supervision, 
when the use of the apparatus has become familiar to them. 

The jury mast, although a very useful appliance under certain 
circumstances, is Inferior to the metallic head rest when accurate 
fixation or support is desired. 

The complications of Pott's disease, abscess and paralysis, 
should be considered and treated as symptoms only — symptoms 
thai may or may not require direct treatment according to the 
indications that have been described. Finally, one should always 
!,,,: "' in mind that the final cure of the disease depends upon the 
increase of the vital force ; thus, the importance of fostering and 
Improving the general well-being of the patient cannot be too 
strongly urged. 



CHAPTER II 



NON-TUBERCULOUS AFFECTIONS OF THE SPINE. 



Fig. 70. 



22^ 



Syphilis. 

Syphilis, in the inherited or in the later stages of the acquired 
form, may affect the bones of the spine and cause local deformity 
and symptoms that cannot be distinguished from those of Pott's 
disease. 

Diagnosis. As compared with tuberculosis, it is a rare disease 
of the spine. 1 Its manifestations are likely to be general in char- 
acter, the deformity of the spine 
being but one of many evidences of 
disease. 

If syphilis were limited to the 
spine and simulated the symptoms 
and the deformity of Pott's disease, 
it would demand the same local 
treatment. Specific remedies should 
*,3s£ be administered when oue has reason 
to suspect the presence of the syph- 
ilitic taint, even if the local disease 
appears to be tuberculous in charac- 
ter. 



4 - Malignant Disease of the Spine. 

Malignant disease of the spine is 
a rare affection, particularly so in 
childhood. Sarcoma is more com- 
mon than carcinoma, and it may 

affect the spine primarily. Carci- 
Vertical anteroposterior section of ■, i i __ 4 

lumbar spine, ,howing deposit ot gum- noma is almost always seconaarj to 

ma in the posterior part of the third and 
fourth vertebrae. ( After Foamier.] 




a primary tumor elsewhere, the spine 
becoming involved by metastasis or 
by contiguity. Schlesinger, 2 in 3720 cases of carcinoma, found 

secondary growths in the spine in 5 1. 



« Jasinski. Archiv f. Dermat. u. Bypb., Bd. Kill. 8. 400. 
* Buckley. Journal of NervotU and " : ' ril > VMyl - 

9 



I.;,, ORTHOPEDIC SURGERY. 

Diagnosis. Malignant disease differs Erom tuberculosis of the 
Bpine in that it- symptoms arc usually more severe ; the pain is 
usually persistent, and it is not relieved by support or recum- 
bency, as is thai of Pott's disease. The constitutional symptoms 
arc in.. re marked, and the steady progress of the disease toward 
a fatal termination is Boon apparent. Locally, the angular 
deformity i< usually slight, and it may be absent. Not infre- 
quently the tumor may he palpated through the abdominal wall. 

Paralysis is a frequent and often an early symptom. In a 
case «>f melanotic sarcoma of the spine in a boy aged twelve 
years, seen recently, complete paralysis of motion and sensation 
in the Lower extremities preceded noticeable symptoms pointing 
to the local disease. 

As has been stated, carcinoma is almost always secondary to 
disease elsewhere; thus, if after the operation for the removal of 
carcinoma symptoms of disease of the spine appear, one should 
suspect this complication. 

Malignant disease of the spine is a fatal affection, and the 
treatment can be but palliative. 

Acute Osteomyelitis of the Spine. 

Infection- osteomyelitis of the spine is comparatively uncom- 
mon. The lower vertebra? are more often affected. In 5 of 41 
cases reported by Eichel 1 the atlo-axoid region was involved. 

Symptoms. The symptoms are similar to those of acute infec- 
tion- processes elsewhere, and are characterized by sudden onset, 
with pain, ft vci, and constitutioual depression. There is local 
pain and tenderness about the spine. Abscess quickly forms ; 
and paralysis from the rapid extension of the disease is a common 
complication. 1 The symptoms due to pyogenic infection and to 
deep-seated abscess arc often pysemic in character, and necrosis 
of the affected vertebral bodies may result in the formation of 
Large sequestra. 

A more localized and more chronic form of osteomyelitis may 
occur, and abscess may be the first sign of the disease. In all 
ca-es of tlii- character, whether acute or chronic, other bones or 
joints or other tissues arc often involved, and in many instances 
an infected wound or discharging ear, for example, may indicate 
the source of infection. 

nch. med. Wochen., 1900, No. 35. 

tsche Zeita. f. Chir., Bd. xli. 



NON-TUBERCULOUS AFFECTIONS OF THE SPINE. 131 

Treatment. The treatment consists in the immediate evacua- 
tion and drainage of the abscess, the removal of the necrosed 
bone if possible, and in supporting the spine during the subse- 
quent stage of weakness. 

Actinomycosis of the Spine. 

Actinomycosis of the spine is an extremely rare disease, and 
need only be mentioned as a possibility. The spine was involved 
secondarily in about 2 per cent, of the reported cases. 1 The diag- 
nosis may be made by the microscopic examination of the dis- 
charge from the sinuses that almost always form when bone is 
affected. 

Injury of the Spine. 

Severe sprains or fractures may simulate disease very closely 
and in some instances, particularly injury of the cervical region, 
diagnosis is practically impossible until after treatment by sup- 
port and fixation has been applied, when, as a rule, if disease be 
absent, the symptoms, even though of long standing, quickly 
subside. 

Fracture of the spine in the middle region may result in angu- 
lar deformity ; and when proper support has been neglected, 
symptoms of pain and weakness, similar to those of Pott's disease, 
may persist indefinitely. 

Sudden forcible compression of one or more of the vertebral 
bodies without displacement and without severe immediate symp- 
toms, other than the slight deformity, may be the result of injury, 
especially falls from a height. These cases are not uncommon, 
and, as the severity of the injury is not often recognized, the 
local deformity, which may not attract attention until several 
weeks after the accident, combined with stiffness and weakness, 
lead to the mistaken diagnosis of Pott's disease. 

Rupture vf spinal ligaments may be caused by forced forward 
bending of the spine. The resulting deformity and weakness 
resemble those caused by a crush of one of the vertebral bodies. 
A number of cases have been described by Painter and Osgood. 2 

1 ErviDg. John* Hopkins Bulletin, November, 1902. 

2 Boston Medical and Surgical Journal, January 2, 1902. 



L32 



ORTHOPEDIC SURGE 11 Y 



Traumatic Spondylitis. 

Kummell 1 has described a form of rarefying ostitis of the spine 
of non-tuberculous origin, apparently caused by injury. It is 
characterized by symptoms of pain and weakness referred to the 
back, and by pronounced rounded kyphosis of the dorsal region. 
Motor disturbances of the lower extremities are frequent. 



Fig. 71. 




Rhachitic kyphosis. 

Cummelr's cases do not differ particularly from those of injury 
tlint have been described. In fact, in the neglected cases of 
injury of the Bpine the pain and weakness may persist indefinitely, 
and the deformity may increase. In certain instances there may 
be a secondary infection, tuberculous or otherwise, at the seat of 
injury, and in others the injury may be the exciting cause of 
spondylitis deformans, but such results are unusual. 



Che med. Wochen., 1895, No. 11. 



NON-TUBERCULOUS AFFECTIOSS OF THE SPINE. 133 

Treatment. In all such cases, and whenever weakness of the 
spine persists, and when motion causes pain, a support should be 
employed as in the treatment of Pott's disease. If possible, 
deformity if of recent origin should be corrected, in part at 
least, either by the method of Calot or by recumbency before 
the support is applied. 

The Rhachitic Spine. 

The rhachitic spine has been described in the consideration of 
the differential diagnosis of Pott's disease (p. 50). It most often 
develops during the first or second year of life, in children who 
sit the greater part of the time; it is, iu fact, simply an exag- 
geration of the contour which is normal in the sitting posture. 
The typical rhachitic kyphosis is thus a rounded projection of the 
lower region of the spine, which is more or less rigid according 
to its duration. If the deformity is extreme there may be a com- 
pensatory backward inclination of the head which may be accom- 
panied by contraction of the posterior group of muscles, ' ' cervical 
opisthotonos.' ' 

Treatment. Aside from the constitutional treatment of the 
rhachitic condition, and from the measures that should be employed 
to improve the nutrition of the muscles in general, the indica- 
tions are to overcome the rigidity and the limitation of motion of 
the spine ; to support it, if necessary, during the stage of weak- 
ness ; and to remove, if possible, the predisposing causes of the 
deformity. 

The correction of the deformity may be accomplished by 
massage, and by direct manipulation of the spine. The child is 
placed, face downward, on a table ; one hand is applied over the 
projection, and with the other the legs are raised to throw the 
spine into a position of overextension. This stretching is per- 
formed slowly and carefully over and over again at morning and 
night, and the manipulation is followed by thorough massage of 
the muscles. If the deformity is marked and if the general 
rhachitic process is still active, the infant may be kept for several 
months in the recumbent posture, on a light frame, in an attitude 
of overextension, as described in the treatment of Pott's disease. 

In older subjects some form of light back brace may be suffi- 
cient in connection with the massage, and systematic correction 
of the deformity. 

The Natural Cure. It may be stated that the rhachitic -pine [s 
to a certain extent corrected when the erect posture is assumed, 



1:; j ORTHOPEDIC SURGERY. 

by the inclination of the pelvis and accompanying lordosis. This 
natural oore is, however, often rather a distribution of deformity 
than a cure, for the upper part of the projection may remain as 
an exaggeration of the normal dorsal kyphosis balanced by an 
exaggerated lordosis, "th< rhachitic attitude" And in other 
instances the persistence of the lumbar kyphosis may induce a 
compensatory flattening of the normal dorsal kyphosis. Thus, 
rhachitis may cause the so-called flat bach as well. 

It may be mentioned that rotary lateral curvature of the spine 
is one of the common deformities induced by rhachitis. This 
distortion is far more serious than the anteroposterior curvature 
with which it is occasionally combined. Its treatment is con- 
sidered in ( lhapter III. 

Infectious Disease of the Coverings or Articulations of the 
Spine. "The Typhoid Spine." 

During the course of or during convalescence from typhoid 
fever, and occasionally after apparent recovery from the disease, 
symptoms of pain, weakness, and stiffness of the back may 
appear. These are caused apparently by secondary infection of 
the til irons coverings and attachments of the spine, similar to the 
more common but more severe forms of periostitis of the tibia or 
other bom-, from the same cause. There is usually pain on 
motion, reflected along the nerves. In some instances this is 
extreme, and there maybe accompanying muscular "cramps" 
and spasm, and pain on pressure over the affected vertebrae. 

In many instances a neurotic element is present, induced, 
doubtless, by the preceding disease. In 8 of 26* cases investigated 
by Lord 1 kyphotic deformity indicated apparently local destruc- 
tiveness of the process. 

Diagnosis. The diagnosis is usually made clear by the history 
of the disease of which it is a complication. 

Treatment. The treatment should be symptomatic. During 
the active stage, if pain is severe, the patient should be kept in 
the recumbent position and opiate- may be administered if neces- 
-;irv. Locally, the application of the Paquelin cautery is of ser- 
vice. A- soon as is practicable a back brace or other support 
should be applied, which should be worn until the symptoms have 
subsided. Recovery may be predicted, the duration of the symp- 

' lira) and Surgical Journal, June 26, 1902. 



XOX-TUBERCULOUS AFFECTIONS OF THE SPINE. 135 

toms averagiDg about six months. Slight restriction of motion 
may persist in the more severe type of cases. 

This description applies particularly to a class of cases of a mild 
type described by Gibney as typhoid spine. Disease of the spine 
complicating typhoid fever was first described by Maisonneuve 
in 1835. Terrillon 1 classifies the lesion of typhoid infection of 
the spine as : 

1. Simple periostitis. 

2. Periostitis with subperiosteal abscess. 

3. Periostitis with ostitis. 

In sixty-eight cases tabulated by Wiirtz 2 six were in children 
under ten years of age. 

Symptoms resembling those described may follow other forms 
of contagious disease, notably scarlet fever, but, as a rule, they 
are much less persistent and severe. 

Infectious Arthritis of the Spine. 

" Gonorrhoeal rheumatism" of the spine is uncommon. Its 
symptoms and pathology resemble those of the typhoid spine. 
Anchylosis is, however, more common as a result than after other 
forms of infection ; in fact, gonorrhoea is supposed to be one of 
the causes of spondylitis deformans. 

The treatment, aside from that of the exciting cause, is symp- 
tomatic. Local support is indicated in many instances. 

The articulation of the occipito-axoid region are sometimes 
affected by what appears to be a form of acute or subacute infec- 
tious arthritis similar in characteristics to acute rheumatism. It 
may follow tonsillitis, diphtheria, or other contagious disease. It 
may be distinguished from tuberculous disease by its acute onset 
and from acute torticollis by the fact that all motions are 
restricted. 

Treatment. The treatment consists in support during the 
acute stage, followed by massage, manipulation, and exercix t<> 
overcome the subsequent stiffness. 

Spondylitis Deformans. 

Synonyms. Osteo-arthritis of the spine; rheumatism of the 
spine; spondylose rhizomelique ; stiffness of the vertebral column. 

i LeProg. M6d., April vi, :- 

- Jahrbuch fur Kinderheilkunde, July, 1902 



L36 



ORTHOPEDIC sriWERY 



Spondylitic deformans is an inflammatory affection of the spine 
terminating in anohylosia and deformity. 

Pathology. The disease is apparently a chronic inflammation 
which affects primarily the Ligaments and the periosteal coverings 
of the spine, a form of ossifying periostitis which binds the ver- 
tebra firmly to one another (Fig. 72). It may begin on the 
lateral or on the anterior aspect of the spine; i.t may be limited 
t<> a particular region, but in most instances it involves the entire 



Pig. 72. 




rlltie deformans (osteo-arthritis). (Goldthwait. 



spine and often the articulations of the ribs as well. The inter- 
vertebral disks atrophy, and the spine becomes anchylosed. In 
some instances the margins of the cartilages proliferate and 
become ossified in a manner characteristic of osteo-arthritis of 



the joints. 



I nder the general term of spondylitis deformans are included, 
in all probability, several varieties of disease, for example: 



XOX-TUBERCULOUS AFFECTIOXS OF THE SPIXE. 137 

1. The affection of the spine may be simply one of the mani- 
festations of general rheumatoid arthritis — rheumatoid arthritis 
of the spine. 

2. The spine may be involved together with one or more of 
the adjacent joints which present the characteristic symptoms of 



Fig. 73. 



Fig. 74. 




Spondylitis deformans, illustrating 
the characteristic deformity. Age of 
the patient, thirty years. Spine 
rigid, with the exception of the oc- 
cipito-axoid articulation. Duration 
two years; cause unknown. Xo 
joints involved. 




Spondylitis deformans in a child. 



the so-called hypertrophic form of arthritis deformans — osteo- 
arthritis of the spine. This form has been designated by Marie 
spondylose rhizomelique, spondylos-.-piiH', rhizo-root, melos- 
extremity, signifying a disease of the Bpine together with the 

adjoining " root " joints. 1 



Marie. Revue de M ■'•<-].. 1898, vol. xviii. 



|;; s ORTHOPEDIC SURGERY. 

[Tie disease may be limited to the spine, and in such cases 
it appears to be entirely distinct from characteristic rheumatoid 
arthritis or osteo-arthritis. It may follow acute rheumatism, it 
may be induced apparently by gonorrhoea, or by other forms of 
infection or by injury — traumatic spondylitis. It may begin 
acutely, Like inflammatory rheumatism, or it may be chronic in 
character and progress slowly. 1 It may be limited to a particular 
section of the spine, although, as a rule, the other regions are 
progressively involved. 

Symptoms. In the ordinary cases there is usually an acute 
onset from which the patient dates the beginning of his trouble, 
often so-called Lumbago, followed by a gradually increasing 
stiffness of the spine and accompanying deformity. The patient 
complains of stiffness, weakness, pain in the loins, and of pain 
radiating forward along the ribs. Sometimes of weakness in the 
Limbs, headache, nervousness, and the like —symptoms that may 
be explained in part by the inflammatory process and by impli- 
cation of the nerve roots, and in part by an accompanying neuras- 
thenia. The direct symptoms are increased by jars which are 
exaggerated by r hc inelasticity of the spine. The disease is 
usually progressive, and terminates finally in complete rigidity 
of the spine, which is bent into a long kyphosis most marked in 
the upper dorsal region, the lumbar lordosis being obliterated 
in many instances (Fig. 73). 

Tin- straightening of the spine in the middle and lower region 
exaggerates the forward thrust of the neck, and in some instances 
the patient- complain of a disturbance of equilibrium, especially 
of a tendency to fall forward. 

When the disease is limited to the spine or to the spine and 
one or more of the Larger joints, the occipito-axoid articulations 
are not usually involved ; but in the general form of the disease — 
rheumatoid arthritis — they are often primarily affected. 

The types of the disease may be illustrated by a brief descrip- 
tion of five cases recently under observation. 

CASE I. Chronic Rheumatoid Arthritis of the Spine. In this 
. in a boy teli years of age, there was characteristic general 
rheumatoid arthritis that involved nearly every joint of the body. 
The entire -pine, even including the occipito-axoid joints, was 
rigid and the |,, :l d was fixed in an attitude of extreme torti- 
collis. 

Neurol. Oentralbl., vol. 11. p. 426. Senator. Berlin, klin. Wochen Novem- 



NON -TUBERCULOUS AFFECTIONS OF THE SPINE. 139 

Case II. Osteo-arthritis of the Spine. "Spondylose rhizo- 

rnelique." A man, aged forty-six years, after repeated attacks 
of so-called rheumatism involving the larger joints, became 1 
gradually disabled because of pain and stiffness of the back and 
because of his inability to stand erect. In this case there was 
complete anchylosis of the spine, except of the small joints of the 

Fig. 75. 




Extreme posterior curvature of the spine in adolescence, showing retraction of tlie abdomen. 
This deformity may be mistaken for spondylitis deformans. 

cervical region, and in addition the ri^ht thigh was flexed upon 
the body at such an angle that the patient could walk only with 
an exaggerated stoop. The joints of the feet were^slightly in- 
volved also. No cause other than exposure to cold and dampness 
could be assigned. The Bymptoms were of two years' duration, 
periods of comfort alternating with disabling attacks of " rheu- 
matism." 



] },, ORTHOPEDIC SURGERY. 

( USE III. Spondylitis Deformans. The spine of this patient, a 
man aged forty-six years, was absolutely anchylosed in the charac- 
teristic position. The ooeipito-axoid joints were not involved. 
Fourteen years before he had suffered from a severe and pro- 
Longed attack of " inflammatory rheumatism, " affecting nearly 
every joint, but not the spine, and during a succeeding period 
of nine year- he had been disabled several times from the same 
cause. Each illness was coincident with gonorrhoea. Five 
years before examination the "rheumatism" had involved the 
spine, and since thou lie had suffered from persistent " lumbago." 
Gradually the stiffness of the spine had increased, but during 
this time he had been free from gonorrhoea and from rheumatism 
as well. The joints were normal in appearance and function. 
This patient suffers principally from nervousness and irritability; 
he is easily Btartled ; he feels as if his forehead were clasped by a 
tight band. J I is direct symptoms are pain in the loins and pain 
radiating under the shoulder-blades, increased by walking or by 
jar-. His equilibrium is disturbed by the forward projection of 
the head and by the obliteration of the normal lordosis, so that 
he feels himself constantly inclined to fall forward, whether he 
La sitting or standing. 

Case [V. In another case very similar to this, in a man 
aged thirty years, the spine had become rigid in a few months. 
The patient ascribed the disease to sleeping out of doors. There 
was in this case coincident tuberculous disease of the lungs. 

Case V. A man, aged sixty-two years, presenting the char- 
acteristic deformity and symptoms of the subacute type, gave the 
following account of the affection: Fifteen years before he had 
suffered from "chronic lumbago." The pain and stiffness, at 
first limited to the lower region of the spine, had, with interven- 
ing periods of remission, gradually ascended, and at the time of 
examination the cervical region was the seat of the more active 
He had been treated by internal remedies, by baths, and 
by change of climate, without avail. He knew he had the "old 
man's Btoop," but he was surprised to learn that the source of 
his symptoms was a disease of the spine. The spine was rigid, 
although not anchylosed, as indicated by the discomfort on 
changing from one position to another. The occipito-axoid 
articulation- and the other joints were free from disease. 

This subacute form of the affection is very common, and, as in 
this instance, the patients arc usually treated for rheumatism, mus- 
cular or otherwise, for many years before the true diagnosis is made. 



XOX-TUBEBCULOUS AFFECTIOXS OF THE SPIXE. \4\ 

Treatment. The local treatment is symptomatic. Massage 
of the muscles, hot baths, and the like, may add to the comfort 
of the patient, but violent exercise or passive movements of the 
spine are harmful. Support is always indicated during the pro- 
gressive stage of the affection, and it is the only efficient remedy. 
The support may be in the form of a light brace or jacket. It is 
particularly efficacious when the disease is limited to the lower 
and middle region of the spine. In such cases under efficient 
protection the muscular spasm subsides, and motion returns in 
some degree. Even in progressive cases one may hope to pre- 
serve the lumbar lordosis, and thus lessen the general effect of 
the deformity when the spine becomes rigid. In certain in- 
stances in which anchylosis is not established, force may be 
employed to improve the contour of the spine, particularly with 
the aim of re-establishing the lumbar lordosis, and thus enabling 
the patient to stand erect. The patient learns by experience 
what exercise or posture increases the discomfort, and this 
should be avoided if possible. The application of cautery is 
often of service, and self-suspension at intervals may relieve the 
dragging sensation in the muscles. Rubber heels are of service 
in lessening the jar. As has been stated, in some cases the dis- 
ease remains localized, but ordinarily it extends along the spine. 
AVhen a part of the spine becomes firmly anchylosed the local 
discomfort lessens or ceases, and is transferred to the part where 
the process is still advancing. 

Kyphosis of Adolescents. A form of extreme kyphosis accom- 
panied by stiffness and discomfort is sometimes seen. It appears 
to be a static deformity induced by overwork in rapidly growing 
adolescents, which finally becomes fixed by accommodative 
changes in the bones and neighboring tissues. It can hardly 
be classified with spondylitis deformans, although there may be 
some difficulty in distinguishing between the two (Fig. 75). 
In favorable cases partial rectification of the deformity by force 
(the Calot operation) is indicated. Afterward support, manipu- 
lation, and exercises should be employed. 

Osteitis Deformans. 

Synonym. Paget's disease. 

Osteitis 'lfformans is a general disease characterized by hyper- 
trophy and softening of the bones. The deformity of tie- Bpine 
i- -imilar to that of spondylitis deformans, but tie' rigidity is nof 



I 12 



ORTHOPEDIC srilCEllY. 



as marked, and the discomfort is far less than in this affection. 
'Tin' disease is described elsewhere. 

Tabetic Deformity of the Spine. In rare instances deform- 
ity of the Bpine, cither posterior or lateral, appears as a compli- 



Fig. 76. 




The neurotic spine. Characteristic attitude. 

cation <>f Locomotor ataxia. Fifteen cases are recorded. 1 The 
characteristics of this form of osteo-arthropathy are described 
elsewhere. 

The Neurotic Spine. 

The "neurotic" Bpine is mucli more common in adolescence 
and in adult life than in childhood, and the subjects, usually 
females, are often of a nervous or neurasthenic type. In certain 



.•11. Bulletin Johne Bopklns Hospital, October, 1902. 



NON-TUBEBCULOUS AFFECTIONS OF THE SPINE. 143 

instances the symptoms appear to be induced by injury, and in 
others by worry or overwork. 

Symptoms. The patient usually complains of a dull pain in 
the back of the neck, or in the lumbar or sacral region, of a con- 
stant tired feeling, and, not infrequently, of sharp neuralgic pain 
localized about a certain point in the spine, often the vertebra 
prominens. The contour of the spine may be normal, but most 
often there is a well-marked tendency toward a forward droop, the 
curve of weakness (Fig. 76). One of the common symptoms of 
the neurotic spine is the extreme local tenderness, or hyperesthesia, 
of the skin at certain points along the spinous processes. Thus, 
if one passes the finger gently along the spine the patient will 
often shrink or cry out because of the pain. As a rule, there is 
no limitation of motion or muscular spasm. The pain is local, 
not referred to the terminations of the nerves ; in fact, the symp- 
toms are in great part subjective and irregular in character, as 
contrasted with those of Pott's disease, which are objective and 
well defined. 

Treatment. The treatment of the neurotic spine must be 
general in character, as indicated by the condition of the patient. 
Locally, a light back brace or a long corset, reinforced if neces- 
sary by light steel back bars, adds greatly to the comfort of the 
patient. The application of the cautery is particularly efficacious 
in relieving the local sensitiveness. Massage and light exercises 
may be employed in the later treatment. Complete recovery is 
usually long delayed. 

The Hysterical Spine. 

The hysterical spine is considered usually as synonymous with 
the neurotic spine, but as there are many individuals who suffer 
from sensitive spines who are not hysterical, it would seem proper 
to limit the latter term to the hysterical class. 

Symptoms, The local symptoms do not differ particularly 
from those of the neurotic spine except that in certain instances 
actual deformity may be present. This is usually an exaggerated 
lateral distortion, most marked in the lumbar region. Like 
hysterical distortions elsewhere, it may follow injury, and it may 
be claimed that this injury was the direct cause of the deformity. 
Except, however, as a possible cause of the appearance of a par- 
ticular manifestation of the mental condition, it ie evident that 
no form of injury could explain the symptoms or the deformity. 



I I i ORTHOPEDIC srili;Ein\ 

Treatment. The local treatment is similar to that of the 
neurotic -pine 

Pain in the Lower Part of the Back. 

Discomfort in the lumbar region of the character of tire, weak- 
oess, or even of actual pain is sometimes an accompaniment of 
disease or displacement of the pelvic or abdominal organs. Pain 
in this region is also a common symptom amoug overworked 
women. It is particularly troublesome when for any reason the 
lumbar lordosis is exaggerated temporarily, as during pregnancy, 
or permanently as a compensatory deformity for dorsal Pott's 
disease, or because of flexion of the thigh after hip disease. 

As a result of strain or other injury symptoms of pain and 
weakness in the lumbar region, increased by sudden motions or 



Fig. 77. 




small pelvis of Prague (median section). Instance of slight forward displacement of fifth 
lumbar vertebra. (Neugebauer.) 

overexertion, may be persistent and disabling. Such cases are 
often classed as chronic lumbago, but it is probable that there is 
in many instances a distinct injury of the ligaments or deep 
muscles of the Bpine aggravated, it may be, in certain instances, 
by rheumatism or other general affection of like character. 

The treatment must be primarily directed to the condition of 
which the pain is a Bymptom. 

When motion causes pain and when the symptoms are per- 
sistent, as in the lumbago type of cases, support is indicated, the 
Knight brace or plaster corset being convenient forms. During 
the more acute stage the application of the cautery and the 
support of intersecting -trips of adhesive plaster, covering a wide 



XOX-TUJBEBCULOUS AFFECTIOXS OF THE SPIXE. 145 

area, will often relieve the pain. Later, massage, electricity, 
and the like are of service. 

In the milder cases, in which the symptoms may be dependent 
on a general descent of the abdominal and pelvic organs, an 
abdominal belt will afford great relief. 

Spondylolisthesis. 

Spondylolisthesis is a deformity in which the body of one of 
the lower lumbar vertebrae, most often the fifth, is displaced for- 
ward and downward (Fig. 77). The displacement is peculiar in 
that the spinous process may remain in its normal position, while 
the laminae become elongated or separated from the displaced 
body. The condition was first described by Killian in 1854, and 
it was thoroughly investigated by Neugebauer 1 in 1890. 

The supposed causes are congenital malformation, injury, and 
possibly disease of the lumbosacral articulation. Lane states 
that slighter degrees of the deformity are often observed among 
laborers. The effect of the displacement is to exaggerate the 
lumbar lordosis, to increase the prominence of the sacrum, and of 
the iliac crests, and to shorten the trunk. The deformity is 
most often seen in women ; in fact, its chief interest lies in its 
effect upon childbirth. As a rule, however, as has been stated 
in the preceding section, an increase of the lumbar lordosis is 
usually attended by a certain degree of discomfort and pain. In 
some instances the deformity induces a swaggering gait resem- 
bling that of bilateral congenital dislocation of the hips. 

Lovett 2 has described a case in which the deformity was the 
result of direct injury. The patient, a young man, was success- 
fully treated by a plaster jacket. Such cases, and those in which 
displacement is the result of disease, may require orthopedic treat- 
ment by braces or other support for the relief of pain and for the 
prevention of further deformity. In the milder type exercises 
and posture are, as a rule, sufficient. 

Deformity Secondary to Sciatica. 

Synonym. Sciatic scoliosis. 

Chronic sciatica often induce- a change "m the attitude and con- 
tour of the spine that may become a permanent deformity if its 

1 Lovett. Transactions American Orthopedic Association, vol. x. p. 22. 
- Transactions American Orthopedic Association, vol. x. 

10 



1 },; ORTHOPEDIC SURGERY. 

cause persists. A- a rule, the patient habitually inclines the 
body away from the painful part in order to relieve it from 
weight, and bends the body slightly forward and abducts the 
limb to relax the ten-ion on the sensitive nerve or plexus of 
nerves. Thus, the pelvis on the affected side projects, there is a 
lateral lumbar convexity toward the opposite side, and often the 
normal lumbal' Lordosis is lessened or lost so that the final result 
may be a persistent lateral curvature, together with a change in 
the anteroposterior contour of the spine. If the deformity per- 
-i-t- a Beoond compensatory curve may appear (Fig. 78). If the 
sciatica i- a symptom of a more widespread neuritis, muscular 
weakness and muscular spasm may cause variations in the typical 
attitude, the muscles of one side being persistently contracted. 

It must be borne in mind that disease of the lumbar spine, or 
of the p.lvic bones or joints, or disease of the adjacent organs or 
part- may set up sciatica ; thus, the cause of pain should be care- 
fully sought for. 

Aside from the direct treatment of sciatica, support for the 
-pine, preferably a light corset, may be indicated, if motion aggra- 
vate- the pain. It the deformity persists it should be corrected 
gradually by repeated applications of the plaster jacket. 

\> uritis in other regions of the spine may cause symptoms of 
reflected pain and local sensitiveness. These symptoms are 
increased by motion, and a certain amount of local deformity, 
similar in character to that due to sciatica, may be present. 

The treatment is similar to that indicated in the former affection. 

Sacro-iliac Disease. 

Tuberculous disease of the sacro-iliac articulation is a rare affec- 
tion, and extremely SO in childhood. 

Symptoms. The Bymptoms are pain, weakness, limp, and 
change in attitude. The pain is referred to the side of the pelvis 
or radiates over the buttock or thigh. It is increased by jars, 
by turning the body suddenly, sometimes by coughing or laugh- 
and a peculiar feeling of insecurity and weakness is some- 
tine- complained of. A- a rule, the body is inclined toward the 
sound limb; thus the pelvis is lowered on the affected side and 
the Leg seems Longer than its fellow. In the early stage of the 
is no deformity of the limb, but if a pelvic abscess 
form- tin- thigh may become flexed. Locally, there may be sen- 
sitiveness to pressure on the articulation, and swelling in the 



XOX-TUBEBCULOUS AFFECTIOXS OF THE SPINE. 147 



Fig. 78. 






neighborhood of the disease, although this is usually a late symp- 
tom. Pain is induced by lateral pressure on the pelvis or by 
any manipulation that disturbs the articulation. 

Abscess finally forms in the majority of cases. It may be 
extrapelvic or intrapelvic. The intrapelvic abscess may present 
above the crest of the ilium, or 
the pus may pass through the 
sciatic notch, or appear in the 
ischiorectal fossa, or break into 
the rectum. 

Diagnosis. Sacro-iliac dis- 
ease may be mistaken for sciatica 
or for disease of the hip or spine. 
The freedom of motion and the 
absence of muscular spasm when 
the pelvis is fixed, if the ex- 
amination is carefully conducted, 
should exclude both the one and 
the other, although the pain on 
lateral pressure, which is de- 
scribed as the most characteris- 
tic symptom, may be simulated 
closely by primary acetabular 
disease. The attitude is similar 
to that of sciatica, but the symp- 
toms of local sensitiveness to jars 
and to manipulation are much 
more marked. 

Prognosis. According to the 
statistics the prognosis is very 
unfavorable, probably because the 
majority of the reported cases 
were in adults and were compli- 
cated by infected and burrowing 
abscesses, which constitute the 
chief danger of this form of tu- 
berculous disease. 

Treatment. The local treat- 
ment consists in protecting the 
diseased parts from injury and in the radical removal of the 
disease if it has reached the -t<-iL r '' of abscess formation, if this be 
feasible. 




Deformity caused by persistem BClatlca 
of the right ride. This attitude Lb simi- 
lar to that symptomatic of sacro-illac dis- 
ease. 



1 |s ORTHOPEDIC srilllERY. 

In the ambulatory treatment of advanced cases a plaster spica 
bandage or a double Thomas hip brace may be indicated, but in 
most instances a broad, strong pelvic girdle, which may be drawn 
tightly aboul the pelvis, will be most efficient. As a temporary 
Bupport wide, encircling bands of adhesive plaster may be used. 
It motion of the spine causes discomfort a spinal brace provided 
with a wide pelvic hand of thin steel that may clasp the pelvis 
firmly is more etlicacions. If the disease is progressive rest in 
bed will be necessary. 

When abscess is present radical treatment is usually indi- 
cated. The articulation should be freely exposed and the dis- 
eased bone should be entirely removed, if possible. Iutrapelvic 
abscess should be drained through a direct communication in 
order to check, if possible, the tendency toward burrowing. 

Injury of the Sacro-iliac Articulation. 

Tu some instances the symptoms of sacro-iliac disease are 
apparently due directly to falls on the buttock or pelvis or to 
strains. In such cases the symptoms are similar in character 
to those described, and they are readily relieved by the same 
treatment. 



CHAPTER III. 

LATERAL CURVATURE OF THE SPINE. 

Synonyms. Rotary lateral curvature — scoliosis. 

Lateral curvature of the spine is an habitual or fixed deformity 
in which the spine is deviated in whole or part to one or the 
other side of the median line. 

Fig. 79. 




Physiological rotation accompanying flexion and lateral inclination of the trunk in the 

normal subject. 

By limiting the term to habitual deformity one excludes simple 
postural inclination of the spine. For example, if one leg were 
considerably shorter than the other the pelvis would be tilted 
downward on the short side, and there would be a compensatory 
curvature of the spine in the erect attitude, which would disap- 
pear in the sitting posture. This accommodative or compensa- 



I 51 1 



ORTHOPEDIC SURGERY. 



tory inclination, and those of similar origin, are not, in the proper 
sense, lateral curvature-. 

In persistent lateral curvature the anterior part of the column, 
made up of the bodies of the vertebrae that support the weight, is 
more distorted than are the spinous processes, because lateral dis- 
tortion is always accompanied by a certain degree of twisting or 
rotation of the vertebral bodies. This rotation is'in the direction 



Fig. SO. 




Congenital total scoliosis. Compare with Fig. 81. 

<»f" the convexity of the curve, and, as the bodies rotate, the 
spinous processes arc carried in the reverse direction. Thus, it is 
thai well-marked rotation may be present, although there may 
be comparatively little lateral deviation of the line of the spinous 
process* s. 

In tie- physiological movements of the spine, simple, direct 
lateral motion — tint is, motion allowed by the small joints of the 
spine and by the lateral compression of the intervertebral disks — 



LATERAL CURVATURE OF THE SPLNE. 151 

is very limited. The larger movements must be accompanied by 
rotation of the vertebral bodies by which this continuous or solid 
part of the column is, as it were, forced from the shortened 
toward the lengthened side (Fig. 79). When, for example, one 
flexes the head to bring the ear as near the shoulder as is possible 
there is necessarily an accompanying rotation of the chin in the 
opposite direction caused by the twisting of the bodies of the 
cervical vertebrae toward the convexity of the curve. Thus torti- 
collis, in which the neck is held in this attitude, causes often a 
fixed rotary lateral curvature of the cervical vertebrae. 

In the simple accommodative lateral inclination of the body to 
one side or the other, the change in contour of the spine would be 
more noticeable if it could be observed from the front rather than 
from the back, and as lateral curvature is simply a persistent 
deviation of the spine, one of the so-called static deformities which 
are directly induced or exaggerated by superincumbent weight, 
it is probable that rotation of the vertebral bodies precedes, in 
most instances, the lateral distortion that first attracts attention. 

It is probable, also, that slight rotation may not cause at once 
an appreciable degree of external distortion, and, although marked 
lateral curvature is necessarily combined with rotation, yet it is 
possible that a slight degree of direct lateral deviation may exist 
unaccompanied by appreciable rotation. Rotation is usually 
understood to imply fixed deformity, while lateral deviation may 
mean simply an habitual posture ; but it is far simpler to consider 
the two as parts of one distortion. The true and important dis- 
tinction is between habitual deformity, implying the habitual 
assumption of an improper attitude in which the accommodative 
changes in structure have not advanced sufficiently to prevent 
voluntary or passive correction, and fixed deformity in which the 
changes in the bones and other tissues have made cure difficull 
or impossible. The evidence of fixed deformity is rotation thai 
persists after the lateral deviation has been overcome. It persists 
because the early and important changes must take place in the 
bodies of the vertebrae that support the weight, but there Is no 
reason to believe that habitual rotation as an accompaniment of 
habitual lateral curvature may not be corrected if it be treated at 
the proper time. 

The necessity for dividing the weight about the centre of 
gravity in order to balance the body in the upright position 
accounts for the distribution and effects of lateral curvature. A- 
the normal contour of the spine is the necessary resull of static 



v> 



1 5: 



ORTHOPEDIC SURGERY. 



conditions, B change from this normal relation of one part neces- 
sitate a corresponding change elsewhere. If there be a primary 
Lumbar curvature and rotation to the left in the lower region, a 
corresponding lateral deviation and rotation to the right in the 
region above usually develops, thus restoring the balance of the 
body. This explains the ordinary S-shaped or double curve of 
scoliosis, one of which is primary and the other secondary. These 
curves may divide the spine equally or there may be a long and 
a short one, and occasionally three distinct curves may be present. 
If the primary curve is slight, the secondary curvature will be 



Fig. 81. 




nital total scoliosis. The rotation is much greater than the lateraVdeviation. 
Compare with Fig. 80. 



slight also, and the primary curve persists doubtless for a time 
before the secondary distortion appears. In some instances the 
spine may he bent laterally into one long curve, " total scoliosis" 
(Fig. 80). This is probably, in many instances at least, the 
initial stage of the ordinary type of scoliosis, the long curve being 
afterward divided, although it may persist. In childhood total 
scoliosis is often combined with general posterior curvature, and 
it is peculiar in that the torsion of the vertebrse may be toward 
the concave instead of the convex side, as is usual, the torsion 
representing probably the early stages of the secondary or com- 
pensatory curve. 



LATERAL CURVATURE OF THE SPLXE. 153 

It has been stated that deformity of one part of the spine is 
usually balanced by deformity of another. This enables the 
trunk to hold the erect posture, and it restores its general sym- 
metry. If, however, a long lateral or a long posterior curvature 

Fig. 82. 




Primary lumbar curvature to the left. A " flat back " marked rotation with but Blight 

lateral curvature. 

persists, the weight can be balanced only by swaying the entire 
body on the pelvis, in the direction opposed to the distortion. 
This restores the balance, but not the symmetry ( Fig. 9 I). 

Rotation and Lateral Deviation. 

Fixed rotation of the spine carries with it, of course, all the 
parts that are attached to it. When the patient stands in theered 



154 



RTHOPEDIC SURGXllY. 



attitude the simple lateral distortion is most noticeable (Fig. 80), 
hut when the body is bent forward the twist of the trunk becomes 
th,. prominent deformity (Fig. SI). If the thoracic region is 
involved, the ribs, on the side toward which the spine is rotated, 
project backward, and on the other side of the spine there is an 
al .normal flatness or depression. The projection of the ribs due 
to the twisting of the thorax is far more noticeable than is the 
simple twisting of the free portions of the spine in the neck or 



Fig. 83. 




-:s with marked posterior deformity. 



loins ; and in these regions the projecting transverse processes 
ed by the thick layers of muscles yet unaccompanied by 
marked lateral deviation, may cause mistakes in diagnosis. In 
the cervical region, for example, as an accompaniment of acute 
torticollis, the projection mav be mistaken for abscess; and in 
the lumbar region it baa been mistaken for a new-growth attached 
to the -pine. 



LATERAL CURVATURE OF THE SPINE. 155 

Although persistent lateral curvature of the spiue is always 
accompanied by rotation, the degree of rotation does not always 
correspond to that of the more evident lateral deviation. In the 
instance cited, rotation in the lumbar region, so extreme as to 
simulate an abnormal growth, may exist with but slight lateral 
distortion ; while in other cases the body appears to be greatly 
displaced to one side, although there may be comparatively little 
tixed rotation. Again, as has been stated, the lateral deviation 
of the trunk is usually more noticeable than the rotation, which 
in the slightest grades of deformity is only made apparent when 
the patient is bent forward so that the back may be inspected in 
the horizontal position. It may be noted, also, that the degree 
of habitual lateral distortion of the body does not correspond to 
the degree of fixed distortion. One individual, by voluntary 
effort, may practically conceal advanced deformity, while another 
who makes no effort to correct the improper posture appears to 
be greatly distorted, although the fixed changes may be very 
slight. 

The effects of the deformity, both general and local, depend 
upon its situation and its degree. In one instance it may be so 
slight as to pass unnoticed, and in another the distortion may 
equal that of Pott's disease (Fig. 83). If compensation be per- 
fect — that is, if the deformity is equally distributed on either 
side of the median line — the general symmetry of the body may 
be but slightly disturbed. Or, if the compensation for the 
primary deformity of the lumbar region is distributed throughout 
the remainder of the spine, noticeable distortion may be insig- 
nificant, but when there is a long curve involving the thoracic 
region the lateral and posterior displacement cannot be concealed 
(Fig. 84). 

Changes in the Anteroposterior Contour. 

Lateral distortion involves, also, secondary changes in the 
anteroposterior outline of the spine. When the distortion is 
marked the stature is shortened, sometimes very noticeably. 
This shortening is, of course, greater when the anteroposterior 
corves are increased in addition to the lateral deviation. And, 
in general, one may recognize two types of lateral curvature: one 
in which the back is flatter than normal, in which the antero- 
posterior curves are diminished, and another in which they are 
increased. 

It has been stated in the account of Pott's disease that deform- 



[56 ORTHOPEDIC SURGERY. 

ity in one segment of the spine always caused a change in the 
contour of the spine as a whole, that an obliteration or a lessen- 
ing of* the concavity of the Lumbar region was accompanied by a 
corresponding flattening of the normal dorsal kyphosis. On the 
Other hand, that an increase in the backward projection of the 
dorsal region caused an increase in the concavity of the parts below. 
The variations in the anteroposterior contour of the spine in 
lateral curvature may be accounted for in the same manner. In 
the one instance the primary deformity is of the lower region, 
and with its accompanying backward twist of the vertebral bodies 
it lessens the lumbar lordosis and tends to flatten the back 
Fig. 82). If, on the other hand, the deformity begins in the 
thoracic region, tin; primary effect is to increase the backward 
projection, ami this in turn tends to exaggerate the lumbar 
lordosis ( Fig. 83). Thus, the shortening of the trunk in the 
lumbar region caused by the lateral deviation may be to a certain 
extent compensated in the first instance, while in the other both 
the primary and secondary distortions tend to reduce the height. 

The ''High" Shoulder and the "High" Hip. 

When the convexity of the primary curve is, for example, to 
the left in the lumbar region, the trunk is displaced somewhat 
to the left, consequently the right " hip " becomes abnormally 
prominent; and in compensation for the displacement below 
there is a corresponding twist in the opposite direction above. 
The spine bending, and at the same time rotating toward the 
right, carrying with it the ribs, elevates the shoulder and makes 
the scapula prominent. Thus it is that in the ordinary S-shaped 
curve the high shoulder and the projecting hip appear usually 
upon the sun.- side of the body. But in less regular varieties of 
distortion, when, for example, there is marked general lateral 
deviation of the trunk as a whole, the high shoulder may be on 
the opposite side | Fig. 84). It is probable that the primary curv- 
ature Is commonly in the lumbar region and toward the left, the 
compensation to the right appearing at a later time. This is 
certainly true of the milder types of postural curvature. 

Pathology. Lateral curvature of the spine is a deformity, 
not a disease, nor is it in the ordinary cases an effect of disease. 
For this reason the description of the pathology which is merely 
a more detailed account of the deformity and of its secondary 
effects u pon the trunk and its contents may, for convenience, 
ede tie- discussion of the etiology. 



LATERAL CURVATURE OF THE SPINE. 



Id 



In such a description one must consider the spine as a whole, a 
column bent and twisted, in which each component segment bears 
its share of the general distortion. The vertebra at the apex of 
each curve shows the greatest change. If the rotation and lateral 
deviation is to the rio-ht the vertebral bodv is somewhat wedge- 
shaped, the apex of the wedge being directed backward and to 
the left. Its lateral diameter is increased and the superior and 



Fig. S4. 




Scoliosis with extreme lateral deviation. 



inferior margins at the narrow .side overhang the centre of the 
body, increasing its lateral concavity (Fig. 88). Similar accom- 
modative changes, although less marked, are t<> be found in tli<' 
articular processes and in the laminae; in fart, all the parte <-ii 
the concave side are broadened, shortened, and Lessened in vertical 
diameter as compared with those on the convex -i<l<- of the -pin'-. 
These changes affect the shape of the neural canal, which^ becomes 



158 



ORTHOPEDIC SURGERY. 



somewhal ovoid in outline, the base being directed toward the 
convexity of the curve (Fig. 89). In the vertebrae, included in 
the compensatory curvature, the deformities are reversed, and 
the intermediate segments show the transitional changes between 



N 







u 



tin- two extremes. The intervertebral disks become wedge-shaped 
also, and atrophied on the side subjected to greatest pressure, the 
changes in these Bofter tissues preceding, undoubtedly, those in 



LATERAL CURVATURE OF THE SPIXE. 



159 



the bones. The articulations of the vertebra? become changed in 
shape and position in the general adaptation to the deformity 
and the ligaments are shortened or lengthened according to their 
relation to the distortion. 

On section the internal structure of the vertebra? shows the 
same adaptive changes that are evident on the exterior. In the 
narrowed parts of the bones that bear the weight the tissue is 
thick and compact, and on the opposite side it is attenuated and 
atrophied. 

The mobility of the spine is lessened by these changes in its 
shape and structure, primarily by 



the distortion, later by the 



Fig. 88. 




Scoliotic vertebrae. (Hoffa). 

shortening of the tissues on the concave side, by the irregularities 
of .the vertebral bodies, by the interference of the newly formed 
or transformed bone which is thrown out about the margins of 
the vertebra? and the articular processes, and by ossification of 
the periosteum and ligamentous coverings of the adjacent bones. 
Thus, in fixed deformity there may be, at the points of greatest 
distortion, practical anchylosis. The muscles of the back, both 
intrinsic and extrinsic, undergo adaptative changes, and, 



[60 ORTHOPEDIC SURGERY. 

rule, they are, in general, relatively weak, especially so if the 
motions of the spine arc much interfered with. 

The distortion of the vertebral column causes, of course, a dis- 
tortion i)\' the trunk of which it is the support, aud this distortion 
Is of the greatest importance in its effect upon the thorax. The 
deformity of the thorax is somewhat difficult to describe, because 
the distortion of the dorsal vertebrae does not affect the thorax 
equally ; thus, it is not twisted as a whole, nor flexed as a whole. 
The nature of the deformity may be better understood by consid- 
ering the sternum as a fixed point; this, as a matter of fact, it is, 
as compared with the spine. At the apex of the convexity of 
the curve the ribs are drawn sharply backward with the trans- 
verse processes to which they are attached; their angles project 
by the side of and beyond, sometimes covering and concealing 
the spinous processes, and the lateral convexity of the chest is 
diminished or lost. On the opposite side the back is broadened 
and flattened. The effect of the rotation is to diminish the 
capacity of the chest on the convex side, and to increase that of 
the concave side (Fig. 90). On the convex side the ribs are 
elevated, and their inclination is increased. On the concave side 
the intercostal spaces are narrowed and the inclination is lessened 
(Fig. 87 i. The anteroposterior diameter of the chest is increased 
or diminished according to the change in the anteroposterior 
contour of the spine. If the dorsal kyphosis is exaggerated the 
effect is to deepen the chest (Fig. 83) ; if it is diminished, the 
diameter of the thorax is correspondingly lessened. 

The cervical section of the spine is not often involved, to a 
marked degree at least, in the lateral deformity. But in extreme 
cases, in which the neck and head are habitually distorted, the 
Bkull may -how secondary changes similar to those induced by 
persistent torticollis. 

\t the other extremity of the spine the pelvis is not, as a rule, 
noticeably deformed. In some instances the oblique diameter, 
opposed to the convexity of the lumbar deformity, may be in- 
creased, and if the Lateral deviation of the lumbar spine is extreme 
tic pelvis may be so tilted that the limb on the elevated side 
becomes practically shorter than its fellow. 

In the changes that have been described the contents of the 
trunk participate to a greater or less degree. The lung on the 
convex Bide is more or less compressed by the distorted ribs and 
by the displaced vertebral bodies. The heart may be displaced 
laterally or upward, according to the position of the deformity, 



LATERAL CURVATURE OF THE SPINE. 



161 



and the bloodvessels are changed in direction, and, it may be, 
altered in calibre. In those cases in which the thorax is markedly 
distorted the effect is similar to that of the deformity of Pott's 
disease ; respiration is shallow and rapid, the pulse- r ate is usually 
increased, and other evidences of interference with the vital 
functions may be apparent. The abdominal organs are affected, 
doubtless, in a similar manner, but symptoms due to this cause 
are not, as a rule, as clearly marked. 1 

Bachmann investigated the secondary changes induced by 
severe scoliotic deformity coming under his observation in the 
pathological institute of Breslau. In 91.3 per cent, of the sub- 
jects defect or disease of the circulatory, and in 99.1 per cent, of 
the respiratory apparatus, was observed. 

Etiology. Relative Frequency. Lateral curvature of the spine 
is one of the most common of deformities. In a period of fifteen 






Fig. 89. 




Change in shape of the spinal canal, broader on the convex side, i Holla. ) 



vears — 1885-1899 — 3252 cases were recorded in the out-patient 
department of the Hospital for Ruptured and Crippled, a number 
only exceeded by that of bow-legs, of which "><»•'}<> cases were 
treated during the same period. 

The 'statistics bearing upon tin- relative frequency of lateral 

1 Bachmann. Die Ven.nderungen an den inneren Organen bei hochgradigen 8k 
und Kyphoskoliosen. Bibliotbeca Medica, Ab. D. 1, H. 1. 1900. 

11 



,,;._) ORTHOPEDIC SURGERY. 

curvature among children in general are those of Drachmann, 
who found among 28,125 Bchool-children (16,789 boys, 11,386 
girls) of Denmark 368 cases of scoliosis (1.3 per cent.), and 
those of Beholder, Werth, and Combe, 1 who found 571 cases of 
lateral curvature among 2314 school-children of Switzerland 
(24.6 per cent.), a discrepancy that is somewhat difficult to 
explain. 

Sex. Lateral curvature of the spine is far more common 
among females than males. Of the 3252 cases referred to, 2554 
, 78.5 per cent.) were in females aud 698 (21.4 per cent.) were in 
males. 

Fig. 90. 



Deformity of the thorax in scoliosis. (Hoffii.) 

The lowest percentage of males in any one of the fifteen years 
was L4.8, the highest 25.1. This proportion of one male to four 
females is somewhat larger than in the smaller groups of cases 
reported by other observers. 

The unequal distribution of the deformity between the sexes 
is of great interest as bearing on the question of etiology; espe- 
cially bo as in the cases that develop in early childhood, sex 
appears to exercise practically no influence. It has been sug- 
gested that curvature of the spine in a girl is looked upon with 
more solicitude by the mother than is the same deformity in a 
boy, therefore, more jrirls are brought for treatment. There may 
be some basis for this argument, for it is certain that distortions 
of the lower extremities are considered of greater importance in 
male than in female children, because of the concealment to be 

1 Extrait des Annals Suisses d'Uygiene Scolaire, 1901. 



LATERAL CURVATURE OF THE SPINE. 163 

afforded by the skirts, if the deformity is not outgrown. But 
granting that statistics are somewhat uureliable, there can be no 
doubt but that this deformity is far more common anions: girls 
than boys and that the disproportion may be explained, in great 
part at least, by the differences in dress and in manner of life. 

Age. One thousand two hundred and ninety-nine (39.9 per 
cent.) of the 3252 patients referred to w T ere less than fourteen 
years of age; 1576 (48.4 per cent.) were between fourteen and 
twenty-one; 377 (11.6 per cent.) were more than twenty-one 
years of age. These statistics simply show the age of the patients 
at the time treatment was sought, and they are of little value 
as an indication of the age at which deformity might have been 
detected had it been looked for. 

There is no reason to suppose that lateral curvature of the 
spine differs in its etiology from similar deformities of other 
parts, except in so far as each region of the body is more or less 
susceptible to deforming influences at one time than another. 

For example, rhachitic deformities of the upper extremities 
practically never develop except in infancy, and they begin to 
correct themselves when the erect posture is assumed or at the 
very time when distortions of similar origin of the lower extrem- 
ities appear or increase. When deformities of this class, whether 
of the spine or limbs, appear in later childhood or adolescence it 
may be assumed that, in many instances at least, the tendency 
toward the particular deformity, or even a slight degree of 
deformity, was acquired at an early age, that it remained latent 
until the conditions appeared which favored its further develop- 
ment. This point is illustrated by the statistics of Eulenburg 
of 1000 cases of lateral curvature analyzed with reference to the 
inception of the deformity. 

Between birth and the sixth year 78 

" the sixth and seventh years 216 

" the seventh and tenth years 564 

" the tenth and fourteenth years 107 

After the fourteenth year 35 

1000 

It will be noted that but 142 (14.2 per cent.) of these patients 
were more than fourteen years of age as contrasted with the 
general statistics of the Hospital for Ruptured and Crippled, in 
which 60 per cent, were beyond this age. 

Dr. Walter Truslow, who for several years had the immediate 
charge of the treatment of lateral curvature at the Hospital for 
Ruptured and Crippled, has prepared for me statistics of a 



1( ;j ORTHOPEDIC SUBQEBY. 

number of the cases treated by gymnastic exercises, which illus- 
trate the same point. 

A..— Age when Treatment was Begun. 

when examined. Males. Females. Total. 

i years l l 

l l 

6 « 1 1 2 

7 "... • ... 4 2 6 

4 7 11 

4 4 8 

LO «< .2 7 9 

U •• . i 13 16 

12 «' 3 16 19 

18 «' 4 28 32 

14 • 5 25 30 

16 " 3 21 24 

16 " 8 14 22 

17 " 2 6 8 

18 " 1 2 3 

19 " ....... 1 1 

20 " 1 1 

21 •■ 4 4 

23 " 1 1 

24 *' 1 1 

1 1 

44 157 201 

B. — Age when the Deformity was Discovered. 

Males. Females. 
Congenital (sex not stated) . . . .2 
During infancy (sex not stated) . . . 19 

Between 3 and 6 years 16 10 6 

6 " 10 " 41 10 31 

10 " 13 " 62 6 56 

13 " 15 27 3 24 

Over 15 years 14 3 11 

Unknown 20 

201 32 128 

But 44 of the 181 patients (22.6 per cent.) were more than 
thirteen years of age at the time when the deformity was first 
noticed, although nearly 50 per cent, were older than this when 
treat 1 1 unt was applied for. In the first table it will be noted 
th.it of the :> > s patients who were ten years of age or less 15, or 
about \0 per cent. <>f the number, were males. In 25 of the 37 
patients in whom the deformity attracted attention at or before 
the sixth year rhachitis was the apparent cause. 

Lateral curvature of the spine is one of the penalties of the 
erect posture, and the force of gravity must be considered both 
as a predisposing and as an exciting cause of the deformity. 

The more direct tendency of the force of gravity is to cause 
the body to fall forward and to increase the posterior curvature 
of the Bpine, but whenever there is a persistent inclination of the 



LATERAL CURVATURE OF THE SPINE. 165 

spine to one or the other side this inclination is likely to be in- 
creased to deformity under favoring conditions. These favoring 
conditions would include general weakness from any cause ; over- 
work that may induce fatigue, and all factors, mechanical or 
otherwise, that may add to the difficulty of holding the trnuk 
erect under the pressure of the superincumbent weight. 

Although it is not difficult to suggest the predisposing causes 
of lateral curvature, it is by no means as easy to point out the 
direct cause of the original inclination of the spine to one or the 
other side of the median line that is the first step toward fixed 
deformity. In a certain number of cases, however, the relation 
between cause and effect is sufficiently evident, and these causes 
may be enumerated before considering the larger class in which 
the etiology is more obscure. 

1. Lateral curvature secondary to deformity of other parts. 

2. Static or compensatory deformity. 

3. Deformity secondary to disease of the nervous system. 

4. Deformity secondary to disease of the thoracic organs. 

5. Incidental deformity. 

6. Deformity due to occupation. 

7. Congenital deformity. 

8. Rhachitic deformity. 

1. Lateral Curvature Secondary to Deformity Else- 
where, (a) Lateral curvature of the spine may be a compen- 
satory effect of torticollis, either congenital or acquired. (b) It 
may be induced by distortion or inequality of the lower extrem- 
ities. For example, fixed adduction of the thigh necessitates an 
upward tilting of the pelvis whenever the limb is brought into 
the normal line, whether the patient is standing, sitting, or 
lying ; and this deformity when extreme may induce lateral 
curvature even in bedridden patients. 

'1. Compensatory Deformity. The same effect is sometimes 
observed in certain instances of inequality of the length of the 
lower extremities. In the erect posture the pelvis is tilted down- 
ward on one side, and this in turn necessitating a twist of the 
spine. Simple inequality of the limbs is an occasional but not a 
common cause of fixed deformity, because its influence ceases in 
the sitting and reclining postures, and because the inequality is 
so often compensated, if it be extreme, by walking on the toe or 
by raising the sole of the shoe. 

An increase in the length of a limb, such as may be caused by 
a fixed equinus of the foot, seems to have more influence in caus- 



li;i; ORTHOPEDIC SVUdERY. 

ing secondary deformity than does shortening, because no attempt 
i- made t<> compensate for the inequality. 

:;. Lateral Curvature Second aey to Paralysis. Lat- 
eral deformity of the spine may be caused indirectly by a number 
of distinct diseases of the nervous system, but in this connection 
only one need be considered — anterior poliomyelitis. This form 
of paralysis may aet in several ways. It may induce deformity 
by distortion of a lower extremity or by inequality in the length 
of the limbs due to retardation of growth. It may predispose 
to deformity by the general weakness that it causes, or the trunk 
may be unbalanced by loss of function in one of the upper 
extremities, but the more extreme cases of deformity are caused 
by unilateral paralysis of the muscles of the trunk. As a result, 
the expansion of one side of the thorax is interfered with and the 
unaffected, or less affected, side taking on increased activity, 
develops at the expense of the disabled part. Thus, the con- 
vexity of the curve is usually toward the sound side. 

4. Lateral Curvature Secondary to Disease within 
the THORACIC Walls. The most common cause of deformity 
of this class is persistent empyema. The lung is primarily com- 
pressed by the effused fluid, and its function is finally impaired 
or abolished by the adhesions that form between it and the chest 
wall, as well as by the extension of the disease to its structure. 
Aa a result, the side of the chest is retracted while the function of 
the unaffected lnng is increased (Fig. 91). Thus, as in paralysis, 
the spine curves with the convexity toward the active side. 

Other affections of the lungs that interfere with the function 
of one side may induce lateral curvature, but the influence is less 
marked and direct than in empyema. 

5. Encidental Lateral Curvature. Lateral curvature 
may be caused by direct injury or by disease of the spine ; for 
example, by fracture or by Pott's disease, or by other organic 
affections of the spine (Fig. 92). Distortion symptomatic of 
-aero-iliac disease, or the more marked deformity caused by 
sciatic or lumbar neuritis (Fig. 78), may if persistent finally 
induce Blight permanent deformity, but such cases hardly deserve 
special consideration. 

6. Lateral Curvature due to Occupation. Lateral 
curvature of ;■ mild degree is incidental to certain occupations that 
require habitual inclination of the body. It is said to be very 
common among -tone-cutters, for example. Such deformity 
developing after the growth of the body has been attained is of 



LATERAL CURVATURE OF THE SPIXE. 



16' 



interest as throwing light upon the etiology of the ordinary form 
of lateral curvature. For if habitual attitudes can thus chancre 
the contour of the developed spine, it is evident that similar 
postures, though far less constant, may influence the spine of a 
growing child, particularly in one predisposed to such distortion. 



Fig. 91. 



FrG. 92. 




Scoliosis following empyema at 
the age of two years. Present age 
nineteen years. 



Scoliosis secondary to lumbar Pott's disease in 
early childhood. 



7. Congenital Lateral Curvatube. Congenital scoliosis 

is uncommon in infants otherwise normal (Fig. 93), but several 
cases have come under my observation at an ;ig<- sufficiently 
early to make the diagnosis absolutely certain. One case, in 
an otherwise well-formed male infant, wag <cen at the ag 
three months. There was well-marked lateral deviation with 
rotation in the dorsal region that had attracted attention soon 
after birth. A second case, in a female child, was seen at about 



Lis 



ORTHOPEDIC srniiERY. 



T h«' same age. The deformity was extreme, and contracted 
tissues <»n the concave side prevented the straightening of the 
spine. There was also an accompanying lumbar hernia. 

The first patient was cured by manipulation and posture before 
the completion <>f the first year ; the second is still under treat- 
ment. A number of cases have been collected from literature 
by rlirschberger. 1 



Fie. 93. 



Fig. 91. 




iital scoliosis. 



Khachitic scoliosis. 



s - Rhachitic Lateral Curvature. Rhachitis predisposes 
to deformity of all parts of the body by weakening the resistance 
of all the tissues. A- is well known, the common deformities 
from this cause are the BO-called rhachitic kyphosis that develops 
in the sitting child, and the distortions of the lower extremities 
iu those who stand and walk. Lateral curvature of the spine 



Lehr der Angeboren Skoliosen. Zeits. f. Ortho. Chir., 1899, B. 



vii.. H. 1. 



LATERAL CURVATURE OF THE SPIXE. 169 

sometimes accompanies the kyphosis in those who do not walk, 
or it may exist independently of it. The lateral inclination is 
induced doubtless by the manner of sitting or by the manner in 
which the child is supported on the mother's arm ; for at this 
period of rapid growth and increased susceptibility to deforming 
influences, even slight and temporary causes of this nature may 
be sufficient to induce the distortion (Fig. 94). Again, when 
the child begins to walk, the tilting of the pelvis due to distortion 
of the limbs, for example, to unilateral knock-knee, may also 
serve to disturb the equilibrium of the body and thus to induce 
lateral distortion. 

How common rhachitic lateral curvature may be it is impos- 
sible to say, but it is probable that if all rhachitic infants and 
children were carefully examined this deformity would be dis- 
covered in many instances in which its existence had not been 
suspected. 

Mayer 1 examined 220 rhachitic infants with reference to this 
point, and in all but 3 found scoliotic deformity. This is not in 
accord with my own experience, but I am convinced that 
rhachitis is of far greater importance in the etiology of lateral 
curvature of the spine than is generally believed, and that a 
large proportion of the severe and intractable cases may be traced 
to this cause. 

In about 15 per cent, of the cases tabulated by Truslow the 
influence of one or more of the causes that have been enumerated 
seemed to be apparent, viz. : 

Congenital deformity 2 

Torticollis 2 

Empyema 4 

Anterior poliomyelitis 3 

Inequality of the legs of more than half an inch 6 

Rhachitis 13 

Total 30 

In the remaining 85 per cent, of the cases the direct cause 
of the deformity was uncertain. 

Hereditary Influence. By many writers the influence of heredity 
is considered an important factor in the etiology. That there is 
such an influence, predisposing to disease as well as to deformity, 
is undoubted, but it is very difficult to establish its connection 
with the ordinary cases. In eleven of 201 cases, lateral curvature 
was present in either the father or mother of the patient ; and in 

" Bull. Medical, June 15, 1001. 



I 70 ORTHOPEDIC SURGERY. 

seventeen others a brother or sister of the patient was deformed 
in a similar manner. 

OCCUPATION. It is well known that occupation may induce 
deformity in the adult, and one looks naturally to occupation as 
8 factor in the causation of lateral curvature in childhood. Occu- 
pation in this class implies school, and it is well known that 
fatigue during school hours may induce improper postures, espe- 
cially if the chair is unsuitable or uncomfortable. The influence 
of habitual posture is indicated in the statistics of lateral curvature 
among school-children recorded by Scholder, Werth, and Combe, 1 
the proportion of deformity steadily rising from the lower to 
the higher classes (Figs. 95 and 96). Under the influence of con- 
stantly recurring fatigue an improper attitude is likely to become 
habitual, its character being influenced by the arrangement of the 
lighl or by the shape of the desk. When a habit of posture is 
acquired it is likely to persist when the sitting posture is assumed 
elsewhere than at school, and the greater liability of girls to the 
deformity may be explained in part by the fact that they sew, or 
read, or play on the piano, while boys are usually engaged during 
th<- same period in active exercise. 

In 4o() cases of lateral curvature under treatment at the Hos- 
pital for Ruptured and Crippled, the occupation and other habits 
that may have influenced the deformity were recorded : 

Occupation : 

School 285 

Factory .... 19 

rierk 13 

Domestic 8 

Millinery, dressmaking, etc 8 

Messenger 3 

Housewife 3 

Teacher 2 

N<> occupation 59 

Total 400 

•'ire : 

Weight on right foot 48 

" left 48 

— 96 
Carries hooks or hahy on right arm . . ' . . . .38 

" left 36 

— 74 
or work in faulty attitude 57 

Carries heavy load on one shoulder 2 

l-e of right arm in occupation 3 

Total 232 

Tic sitting posture i- not the only one in which improper 
attitudes may be persistently assumed, in fact, it has been sug- 
gested that the posture during sleep may influence the inclination 

1 Loc. cit. 






LA TERA L CURA r A T URE OF THE SPINE. 1 7 j 

of the body during the hours of activity. But the sitting- posture 
is the one in which the muscular support is most likely to be 
relaxed, and in which a tendency toward lateral inclination is 
most likely to be acquired, since children do not often retain a 
fixed attitude in the erect posture for any length of time. Brad- 
ford and Lovett record an observation of the attitudes of sixtv- 
seven healthy adults undergoing a written examination. At the 
end of the second hour a lateral inclination of the body was evident 
in all, and in three-fourths of the number the general inclination 

(a) With double lateral curves 22 

(0) With triple lateral curves 8 

— 30 
4. Lateral Deviation More Marked than Rotation ; Direction of the Curves : 

Right dorsal, left lumbar type : 

(a) Single lateral curve 22 

(b) Double lateral curves 71 

(c) Triple lateral curves 6 

— 99 
Left dorsal, right lumbar type : 

(a) Single lateral curve 3 

(6) Double lateral curves 8 

(c) Triple lateral curves 3 

— 14 

Total 201 

It will be noted that in twenty-one instances anteroposterior 
deformity existed without lateral deviation, and that in thirty- 
seven instances it was accompanied by lateral deviation. In the 
remaining 144 cases, rotation was more marked than lateral devia- 
tion in 30 cases, and lateral deviation more marked than rotation 
in 113. In the entire number of cases in which lateral deviation 
was present it was single in 39 cases, double in 117 cases, triple 
in 24 cases. 

In 890 cases of lateral curvature tabulated by Schulthess the 
deformitv was as follows i 1 

Posture induced by improper desk and chair. (Scudder.) 

of the body was to the right. In about tin's proportion of the 
cases of lateral curvature the type of fixed deformity is to the left 
in the lumbar and to the right in the dorsal region, and it is 
natural to look upon the occupation as the important factor in 
determining the direction of the deformity. If it be assumed 
that the distortion i- caused or influenced by the attitude assumed 
during school hours it would appear that the primary deformity 
should be more often of the lumbar region, for in tli<- sitting 
picture the lumbar lordosis is lessened or lost, thus the bodies of 



172 ORTHOPEDIC SURGERY. 

the vertebrae in the Lumbar region arc subjected to greater pressure 
than in the dorsal region — a pressure which might induce the 
accommodative changes in the bones that accompany persistent 
deformity. 

The possibility of distinguishing the varieties of lateral curva- 
ture in which the primary distortion is lumbar from those in 
which it i-< dorsal, by the flattening of the dorsal kyphosis in the 
former, and it> exaggeration in the latter instance, has been 
mentioned. 

- . 7 » v^uiiiue,* 

the proportion of deformity steadily rising from the lower to 
the higher classes (Figs. 95 and 96). Under the influence of con- 
stantly recurring fatigue an improper attitude is likely to become 
habitual, its character being influenced by the arrangement of the 
light or by the shape of the desk. When a habit of posture is 
acquired it is likely to persist when the sitting posture is assumed 
elsewhere than at school, and the greater liability of girls to the 
deformity may be explained in part by the fact that they sew, or 
read, or play on the piano, while boys are usually engaged during 
the same period in active exercise. 

In 100 cases of lateral curvature under treatment at the Hos- 
pital for Ruptured and Crippled, the occupation and other habits 
that may have influenced the deformity were recorded : 

cupatton : 

■1 285 

Factory .... 19 

Clerk 13 

Domestic 8 

Millinery, dressmaking, etc 8 

M e ss en ger 3 

Housewife 3 

Teacher . 2 

. 59 

Varieties of Deformity. According to statistics from various 
sources, about three-fourths of the well-developed double curves 
nt t,,, ' spine are convex to the right in the dorsal and to the 
Left in the lumbar region, and, as the distortion of the thorax 
is more noticeable of the two, it usually classifies the deformity 
as righl or left. The dorsal curvature may be either primary or 
ndary, and the relative frequency of the original deformity, 
whether lumbar or dorsal, is in doubt, with the probability in 
favor of the former. 

Summary of varieties of deformity of the spine under treatment, 
1899-1900, at the Hospital for Ruptured and Crippled, tabulated 
by I >r. Truslow : 



LATERAL CURVATURE OF THE SPIXE. 173 

1. Simple Anteroposterior Deformities : 

(a) Kyphosis 10 

Kypholordosis 1 

Lordosis 1 

— 12 
Round shoulders : 

(b) Abducted scapulae 7 

Elevated scapulae 2 

— 9 

2. Anteroposterior Abnormalities Most Marked, but Accompanied by 

Lateral Deviation : 

(a) With single lateral curve 14 

(6) With double lateral curves 16 

(c) With triple lateral curves 7 

— 37 

3. Rotation More Marked than Lateral Deviation : 

(a) With double lateral curves 22 

(6) With triple lateral curves 8 

4. Lateral Deviation More Marked than Rotation ; Direction of the Curves : 

Right dorsal, left lumbar type : 

(a) Single lateral curve 22 

(b) Double lateral curves 71 

(c) Triple lateral curves 6 

— 99 
Left dorsal, right lumbar type : 

(a) Single lateral curve 3 

(&) Double lateral curves 8 

(c) Triple lateral curves 3 

— 14 

Total 201 

It will be noted that in twenty-one instances anteroposterior 
deformity existed without lateral deviation, and that in thirty- 
seven instances it was accompanied by lateral deviation. In the 
remaining 144 cases, rotation was more marked than lateral devia- 
tion in 30 cases, and lateral deviation more marked than rotation 
in 113. In the entire number of cases in which lateral deviation 
was present it was single in 39 cases, double in 117 cases, triple 
in 24 cases. 

In 890 cases of lateral curvature tabulated by Schulthess the 
deformity was as follows : l 

Left. Rigid. Total. 
Total scoliosis (single curve affecting the entire 

spine) 173 23 196 

Lumbar scoliosis (single curve limited to the 

lumbar regionj 63 34 97 

Lumbodorsal scoliosis (single curve limited to 

lumbodorsal region) 184 164 

Complicated scoliosis : 

(a) Right dorsal, left lumbar 191 

(b) Left dorsal, right lumbar .... 58 ... 249 

478 412 890 

It will be noted that a very large proportion of these cases 
were in the early stage of deformity, as indicated by the absence 
of compensatory curves ; that in 80 per cent, of the 293 cases in 

1 Zeits. f. Orth. Chir., 1902, Bd. x. 



174 OR TH OPE DIC SURGEB Y. 

which the curve was general or most marked in the lumbar 
region, the inclination was to the left, and of the complicated or 
more fully developed cases in which the curve was double, 73 per 
cent, were of the right dorsal, left lumbar type. 

Symptoms. In the large proportion of cases the first symp- 
tom is the deformity. This is often discovered by the dress- 
maker at the age when the clothing is made to fit the figure more 
closely. In certain instances the deformity may be preceded or 
accompanied by pain. This was present to a greater or less 
degree in about one-quarter of the cases examined by Truslow. 
Pain may be simply the discomfort or the " dragging" sensation 
of fatigue, usually referred to the lumbar region, or it may be 
severe and neuralgic in type. The latter variety is more common 
in the cases in which the deformity is extreme. It is said to be 
the result of pressure on nerves, but this cause is exceptional in 
ordinary cases, as it is as often referred to the convex as to the 
concave side. When the deformity is extreme — for example, 
when the ribs and the iliac crest are in contact — direct pressure 
undoubtedly explains the local discomfort referred to this region. 
There are also more general symptoms of a neurasthenic or 
hysterical nature that may be due in part to the deformity and 
in part to the debility of which it may be a result or accom- 
paniment. For it must be borne in mind that lateral curvature 
is often symptomatic of general weakness, as is shown by the 
fact that it is often accompanied by other deformities, par- 
ticularly by the weak foot. In many instances symptoms of 
weakness and awkwardness precede the deformity. Truslow 
states that in a large proportion of the cases investigated the 
patients had been distinctly less active than their companions, 
that they did not enjoy exercise, and were inclined to lead seden- 
tary lives. Teschner 1 has called attention to the same peculiarity. 
He states that the patients are often indifferent, apathetic, and 
lazy. He has noted also a peculiar lack of co-ordination and mus- 
cular control as a common accompaniment of the deformity. 
These symptoms apply particularly to the period of adolescence, 
the time of rapid growth and instability, when any latent 
deformity or weakness is likely to be exaggerated. In younger 
subjects such symptoms are far less marked or are absent. In 
the cases in which the deformity is extreme, symptoms due to 
interference with the respiratory and circulatory apparatus, or to 

1 Medical Record. December 16, 1893. 



LATERAL CURVATURE OF THE SPINE. 175 

displacement of the abdominal organs, may be present. These 
are, however, rather unusual. 

Diagnosis. Posture. Lateral curvature of the spine is a 
simple deformity unaccompanied by the symptoms of disease. 
When the patient stands with the back and hips bare, the inclina- 
tion of the body to one or the other side and the general want 
of symmetry are usually apparent, even in the earliest stage of 
the affection. For, as has been stated, the habitual assumption 
of a certain posture precedes fixed changes in and about the spine, 
and this posture will appear when the patient is asked to stand 
in the usual manner. If the inclination of the body is toward 
the left (Fig. 80), the left arm will hang in close apposition to 
its lateral border, Avhile on the right side an interval will appear 
between the arm and the trunk. If there be a slight lumbar 
curve to the left (Fig. 82), the right iliac crest will be accent- 
uated. The curvature in the dorsal region makes one shoulder 
higher than the other (Fig. *91), the scapula on the affected side 
projects, and the distance between its posterior border and the 
median line is increased. Rotation of the spine is shown by the 
fulness or projection of one side accompanied by a corresponding 
flatness on the other. This is more noticeable when the patient 
bends the body forward so that the horizontal plane of the back 
is brought into view (Fig. 81). Corresponding changes, though 
of a less marked degree, appear on the anterior surface of the 
body ; for example, the apparent diminution in the size of the 
mamma on the side opposite the convexity of the posterior curve 
and its relative depression or elevation may attract attention. 

It seems probable that a change in the anteroposterior contour 
of the spine precedes, in many instances, the lateral deviation. 
Thus, a general droop of the body associated with round shoulders 
and a flattening of the chest may be regarded as a predisposing 
cause or an early symptom of more serious deformity. 

Mobility. As has been stated, it may be assumed that habitual 
posture precedes actual deformity. Habitual posture implies dis- 
use of certain attitudes and motions, thus limitation of the normal 
flexibility of the spine may be considered as one of the earliest 
signs of progressive deformity. The test of the motion of the 
different regions of the spine is, therefore, a necessary part of the 
examination. To test the motion in the lumbar region, one fixes 
the pelvis with the hands while the patient sways the body in 
the four directions and rotates it from side to side. It is sug- 
gested by Bradford and Lovett that direct lateral flexibility may 



L76 



ORTHOPEDIC SURGERY. 



be tested by placing blocks of wood under one foot until the limit 
of lateral flexion is reached, as shown by the inability of the 
patient to hold the elevated Limb in the extended position. The 
experiment is then repeated on the opposite side. The flexibility 
of the upper part of the trunk may be tested by fixing the part 
below with the hands while the patient flexes, extends, and rotates 
the body. It is important, also, to test the range of motion at 
the shoulder-joints. The normal individual should be able to 



Fig. 97. 











Br ! : M 


v 










V 




iH 






-l*r— • -l~ V 






V 






























1 






V 




W 






^^H 




W~ ' 4- 


Wi 




I ' i- i 


/■ 






■ 







The thread screen. From the Boston Children's Hospital Report. 



bold the arms extended directly above the head without increas- 
ing the Lumbar Lordosis. In many instances, however, it will be 

,( d that then- [g a marked restriction of this motion j in fact, 

such restriction is almost always an accompaniment of so-called 
round shoulders. 

I'd' beight and weight, the circumference and the expansion 
of tin- chest should be investigated, and a test of the muscular 



LA TEE A L CURVATURE OF THE SPIXE. 177 

strength, not only of the muscles of the trunk, but of the mem- 
bers as well, is of advantage as throwing light on the etiology 
and indicating the general line of treatment. 

Record. The most reliable of the graphic records to be used 
in connection with the history are photographs. The patient 
may stand behind a thread screen (Fig. 97) iu the habitual atti- 
tude. The spinous processes, the iliac crests, and the angles of 
the scapula? having been marked, the exact amount of lateral 
deviation of the trunk will be shown. The rotation may be indi- 
cated also by photographing the patient in the recumbent posture. 

The rotation of the spine is the most important indication of 
deformity. This may be recorded with sufficient accuracy by 
taking direct tracings of half the trunk at fixed points by means 
of a lead or zinc tape while the patient lies in the recumbent 
posture. 

At the Hospital for Ruptured and Crippled the shadow of the 
trunk cast by an electric light at a fixed distance is traced upon 
a large sheet of paper. Upon this outline the position of the 
more important landmarks is indicated. The degree of rotation 
is shown by transverse tracings and the line of the spinous 
processes is ascertained by applying a broad strip of adhesive 
plaster to the back upon which the tip of each spinous process is 
marked. The anteroposterior outline of the spine should be 
recorded, also the general attitude aud the presence or absence 
of other evidences of weakness such as knock-knees and weak 
feet. 

Prognosis. In the development of lateral curvature there is 
doubtless a preliminary or predisposing stage — a stage of progres- 
sion and a stage of arrest. All deformities of this class are more 
likely to progress during the growing period. They are likely 
to become stationary when the period of growth is completed. 
Thus, the prognosis is worse when the deformity begins at an 
early age than when it first appears in adolescence. The most 
extreme and intractable of the simple cases are the result of 
rhachitis, in which the deformity appearing in infancy or early 
childhood has increased with the growth of the child. 

If the causes of deformity arc such that they operate to check 
the equal development of the affected part, the prognosis is even 
more directly influenced by the age of the patient For example, 
empyema, even if the lung is irreparably damaged, doc- not cause 
appreciable deformity in tie- adult, but in childhood the functional 
activity and the growth of the side of the thorax arc checked, in 

12 



17S ORTHOPEDIC SUBGEBT. 

addition to the direct effect of the adhesions and contractions due 
to the disease ; thus, the deformity is likely to be progressive in 
spite of the treatment. The same is true of paralytic deformity. 
In the ordinary type of lateral curvature in the adolescent girl, 
the prognosis is influenced, of course, by the general condition 
of the patient and by the character of the occupation. As far 
as the local deformity is concerned, the prognosis as regards im- 
provement or cure depends in great measure upon the fixed changes 
that have taken place, and upon the degree of voluntary and 
involuntary rectification that is possible. In some instances the 
postural distortion may be considerable, yet the fixed deformity 
may be very slight, while in other instances the fixed rotation of 
the -pine may be marked, although the lateral distortion is less 
noticeable. 

A -ingle curve is more amenable to treatment than is a double 
or triple distortion, because it indicates an earlier stage of 
deformity and because the treatment maybe more effective when 
applied to one deformity than to several. If, however, the single 
curve is fixed, the appearance of a secondary or compensatory 
curve at another part of the spine is probable, in spite of pre- 
ventive treatment. 

In the majority of cases, fixed deformity of the spine as indi- 
cated by rotation is already present Avhen the patient is brought 
for treatment. This fixed deformity might be overcome doubt- 
less in certain cases, and complete cure might be obtained were 
all the conditions favorable. But in the ordinary sense a cure 
means the relief of symptoms, the checking of the progress of 
deformity, and the restoration of the general symmetry of the 
trunk. Such a cure may be obtained in most instances. The 
deformity of the spine becomes symmetrically divided on either 
Bide of the median line, the changes incident to maturity, par- 
ticularly the increased amount of adipose tissue, serve to con- 
oid the irregularities of the outline, and the history of the 
distortion is completed. 

In certain instances, particularly in well-marked cases, the 
deformity may increase in adult life and even in old age. In 
such cases, tie- symptoms of discomfort and actual pain may be 
troublesome throughout life, especially in the overworked and 
debilitated class. The symptoms directly incident to the com- 
pression and distortion of the internal organs have been men- 
tinned. 

The great majority of cases that develop or that are discovered 



LATERAL CURVATURE OF THE SPINE. 179 

in adolescence progress for a time and come to an end on the 
cessation of growth, causing finally no symptoms other than the 
loss of symmetry that may be more or less satisfactorily concealed 
by the art of the dressmaker and by the corset. 

It would appear, then, that lateral curvature of the spine is 
always of sufficient gravity to merit treatment and supervision 
until its cure or arrest is assured. If its discovery leads to active 
efforts to improve the general condition and to avoid uuhealthful 
influences it may be even of benefit to the patient. 

Lateral curvature in a young child is of far greater importance 
because of the probability of an increase of deformity. Extreme 
deformity is always a source of weakness and usually of discom- 
fort to the patient. Incipient deformity may be cured and cure 
is not impossible even when deformity is more advanced, but iu 
this more than in any other postural deformity, absolute cure 
implies early diagnosis and prevention, rather than the correction 
of fixed distortion. 

Recapitulation. It seems probable that in the ordinary type 
of lateral curvature of the spine the first step is a change in the 
relation of the bodies of the vertebra? to one another ; that a 
persistent lateral inclination and rotation of the anterior part of 
the column precedes the lateral incliuation of the trunk which 
first calls attention to the deformity. This postural distortion 
becomes fixed by accommodative changes in the muscles and 
other tissues about the spine, and, finally, it is confirmed by 
changes in the shape of the vertebral bodies and by the general 
changes in the trunk as a whole. Thus, if one might observe 
the inception and development of lateral curvature of the common 
type he would note, first, that the trunk was more often flexed to 
one side than to the other, and that this attitude gradually became 
habitual. Lateral inclination of the trunk necessitates, of course, 
lateral deviation and rotation of the bodies of the vertebra?, and 
the habitual assumption of such a posture implies disuse of other 
postures and thus disuse of normal motion. 

Disuse of motion in any direction is followed by diminished 
power in the inactive muscles, and, as has been stated, habitual 
deformity is followed by accommodative changes \<> a greater or 
Less degree in the various tissues whose functions have been 
changed or modified. 

Thus the progress of the deformity would be shown : 

1. By the habitual assumption of an attitude simulating 
deformity. 



I s ( , ORTHOPEDIC SURG Ell Y. 

2, By limitation of motion in the directions opposed to the 
habitual attitudes. 

3. By fixed lateral deviation of the spine accompanied by 
rotation or twisting of the column. 

One rarely has the opportunity to note the development of 
lateral curvature, and w hen patients are brought for treatment 
fixed deformity is usually present. It is extremely difficult to 
entirely overcome fixed distortion, while it is comparatively easy 
to cornet simple postural deformity in which the secondary 
changes are absent or but slightly advanced. On this account it 
Lb customary to divide lateral curvature into two classes — the 
bin and the false — or to speak of rotary lateral curvature as 
distinct from lateral curvature. Thus, the term true or rotary 
curvature would be limited to those cases in which the changes 
are fixed and in which cure is practically impossible, while false 
or simple or postural lateral curvature would include the early or 
curable class. But as the two forms are simply stages in the 
-ante process it would seem preferable to speak of the incipient 
and the later stages of lateral curvature, or of reducible or 
irreducible deformity, the distinctions that are made in classifying 
distortion- of similar origin elsewhere. 

This point of view is of advantage because it relieves the sub- 
y <t of much of the obscurity that has resulted from this arbitrary 
division. It emphasizes the fact, also, that the habitual assump- 
tion of an improper attitude that simulates deformity is the first 
step toward permanent distortion, particularly in individuals who 
by inheritance or by constitutional tendency or by occupation are 
predisposed to such deformity. 

The Prevention of Deformity. Prevention includes the 
avoidance of all the predisposing or exciting causes of weakness 
as well as of deformity. These it is hardly necessary to enu- 
merate. 

The first and most important preventive measure is the discov- 
ery of deformity or the tendency to deformity at a time when it 
may be checked or cured. To discover deformity at this period 
of it- development one must look for it, and it would seem 
that a yearly inspection at least of the naked bodies of all chil- 
dren Bhould become a routine practice of the family physican. 
inity in this sense Includes not only fixed distortions, but 
improper attitudes and postures of every variety as well. 

'I"he importance of the attitude which is habitually assumed 
during occupation has been mentioned. Therefore, the provision 



LATERAL CURVATURE OF THE SPLXE. 



181 



of proper desks and seats for school-children is a very essential 
part of preventive treatment. 

The seat of the chair should be deep enough to support the 
thighs, yet it should not interfere with flexion at the knees. It 
should be of such height as to allow the feet to rest firmly on the 
floor, and it should be inclined slightly backward. The back of 
the chair should extend to about the level of the shoulders ; it 
should be inclined slightly backward, but arched somewhat for- 
ward in the lumbar region in order to conform to the normal 
lordosis when the child sits in the erect posture. The desk 
should be as close to the body as is possible, so that the child 
need not lean far forward when reading or writing. The height 

o o o 



Fig. ?8. 




Adjustable school desks and seats. Scheiber and Klein. (Redard. 



of the desk should be slightly less than the level of the elbows 
when the child sits erect, and the inclination should be sufficient 
to hold the book at the proper distance from the eyes (Figs. 98 
and 99). The vertical handwriting is of advantage in that the 
children are taught to face the desk squarely, as contrasted with 
the lateral twist of the body, the usual attitude for writing. 

Treatment. The treatment of rotary lateral curvature of the 
spine does not differ in principle from the treatment of any other 
weakness or deformity, but the application of this principle Is 
difficult and the results are far from definite and satisfactory. 
This explains, doubtless, the apparently opposing theories and 
methods of treatment that are still advocated. 

A brief account, then, of the rules of treatment as applied to 



182 



nllTUOPEDIC SUHC Ell Y. 



weakness in general and of the exceptions that must be made in 
(heir application to ourvature of the spine may be illustrated by 
comparing this deformity with another, of similar causation. 

One may take for comparison the weak foot, since the foot 
corresponds more nearly to the spine than does a simple joint, 
because of the Dumber of hones of which it is made up. In the 
treatment of the weak foot one must first overcome all restrictions 
to passive motion, even by force, if this be necessary. One next 
endeavors to strengthen the muscles that support the foot, by 



Fig. 99. 




Adjustable school seat. (Miller and Stone.) 



appropriate exercises, particularly those whose action is opposed 
to the habitual deformity. The avoidance of improper attitudes 
and of overfatigue that favor deformity is also essential. Finally, 
if persistent deformity makes it evident that the voluntary or 
natural efforts of the patient are inefficient, a brace is employed 
to support the fool in proper position in order to aid the weakened 
muscles and to hold the joints in the normal position in which 
they may work to advantage. Under these conditions one would 
' an immediate relief of discomfort and a progressive trans- 
formation of the internal structure of the foot, which in favorable 



LATERAL CURVATURE OF THE SPINE. 183 

cases would lead to complete cure of the deformity and of the 
weakness as well. 

The principles of the treatment of any variety of weakness not 
directly induced by disease are, then : 

1. To overcome all restriction to passive motion. 

2. To strengthen the weakened muscles, especially those whose 
action is opposed to habitual deformity. 

3. To insist on the avoidance of overfatigue and improper 
postures. 

4. To support the weak part by a brace if deformity cannot 
be prevented otherwise. 

In applying these principles to the treatment of the distorted 
spine the first step, the removal of restriction to passive motion 
in all directions, is difficult because of the variety of muscles and 
other tissues that may have become involved, and because the 
bodies of the vertebrae lying within the trunk, of which the dis- 
tortion is always greater than of the spinous processes, can 
be only indirectly affected by voluntary or by passive move- 
ments. 

The cultivation of the muscular system, and particularly of 
those muscles whose action is opposed to the habitual deformity, 
is the second indication in treatment. As applied to the treat- 
ment of the weak foot in which the adductor and extensor muscles 
are at fault, this treatment is simple, but as applied to the trunk 
it is difficult, because there are in nearly all developed cases two 
curves, the one primary and the other secondary, in direction 
directly opposed to one another. These opposing curves are 
supplied in great part by the same muscles, and it is difficult by 
voluntary effort to straighten the convexity of one without at the 
same time increasing that of the other. 

The third principle in treatment is the avoidance of predispos- 
ing attitudes and of overwork. This again may be more easily 
applied to the treatment of the weak foot; first, because it is 
relieved from strain when the sitting posture is assumed, and 
because active use, as in walking, may be utilized as an exercise 
for strengthening the muscles. But the muscles of the trunk are 
not exercised to any extent in ordinary walking, which is for 
many individuals the only form of activity, nor is the spine 
relieved from weight when the patient is Beated. On the con- 
trary, it is in this restful attitude that the deformities of the spine 
are usually most marked. Thus, only in the recumbent attitude 
is the -pine entirely relieved from -train, and even at such times 



I. i ORTHOPEDIC SURGERY. 

the deformities may be favored by the habitual attitudes of the 
patieut 

The weak fool can be supported by a brace, which does not in- 
terfere with its activity, but which, on the contrary, aids normal 
motion by holding the hones in proper relation to one another. 
Bui in the treatment of the spine the conditions are quite differ- 
ent. Bince the back cannot be supported without at the same 
time restraining its normal motion. Finally, no brace applied 
to the trunk is efficient, for while it may prevent the lateral 
deviation it can exercise little direct action in overcoming the 
rotation of the spinal column. 

This comparative method of exposition has been adopted in 
order to illustrate the fact that it is not the difficulty of formu- 
lating principles, but the difficulty of applying them that makes 
the therapeutics of rotary lateral curvature of the spine perplex- 
ing. In practice one must recognize the limitations of all systems 
of treatment as applied to this particular deformity, and select 
ami combine methods that may be most applicable to the par- 
ticular case under treatment. 

For example, in the treatment of rhachitic scoliosis in a young 
child oik- cannot count upon the voluntary assistance of the 
patient ; therefore, treatment by simple gymnastic exercises is 
impracticable. In this class of cases forcible correction of the 
deformity and retention by the use of apparatus, combined with 
massage, and even the removal of superincumbent weight by 
recumbency would be the treatment of selection. At this age the 
trunk is flexible and the deformity may be progressively reduced 
by forcible manipulation, followed by fixation of the trunk in the 
Improved position. By such means one may expect at this period 
of rapid growth to induce a transformation of the deformed verte- 
bral bodies to an approximation at least of the normal. In such 
cases tic correction of the underlying deformity of the bones which 
must almost inevitably increase with the growth of the patient 
would quite outweigh the disadvantage of depriving the muscles 
of their normal stimulus during the corrective period of treatment. 

In the ordinary ('//>< of scoliosis in older subjects, particularly 
if tie distortion i- moderate in degree and the changes in the 
but slight, one would expect to attain the best result by 
gymnastic training and by regulation of the postures. Although 
even in tin- class supports may be of service, if by such means 
He- trunk may !»<• held in an overcorrected attitude until the 
deformity hal.it i- overcome. 



LATERAL CURVATURE OF THE SPINE. 185 

The advisability of a change of occupation has been mentioned. 
It is probable that if the patient with incipient or even more 
pronounced curvature of the spine were removed from school, 
were transferred to the countrv where during the succeeding years 
of childhood and adolescence much of the time might be passed 
in active exercise in the open air, the final result would compare 
very favorably with that attained by active treatment under less 
favorable circumstances. Such complete change of occupation 
and surroundings is, of course, impracticable in most instances. 
Lateral curvature of the spine is not a serious disease, it is simply 
an insidious distortion which rarely causes more than compara- 
tively slight discomfort. It is usually overlooked in the incipient 
stage when it might be checked or cured, and when the deformity 
finally attracts attention it is often no longer amenable to cor- 
rection. Under these circumstances, with the uncertainty that 
exists as to the ultimate prognosis, the tediousness of treatment 
which cannot offer the assurance of definite cure, it is not strange 
that the affection is not one for the treatment of which any con- 
siderable sacrifice is considered essential. 

A third class of cases would include the fixed deformity in older 
subjects, many of whom are obliged to assume in their occupations 
attitudes that predispose to deformity. In the treatment of this 
class a support to relieve discomfort and to prevent exaggerated 
distortion may be essential. 

Thus, there are three classes or types of scoliosis in which 
distinct methods of treatment may be employed. 

1. Curvatures in very young children, in which forcible cor- 
rection and fixation are indicated in the hope of correcting the 
deformity of the bones and curing the distortion. 

2. The milder degrees of deformity for which treatment by 
exercises and if possible by favoring postures is that of selection, 
and in which support is a temporary and incidental adjunct. 

3. The third class would include fixed deformity in older sub- 
jects as well as those cases caused by disease ; as, for example, 
by paralysis, by empyema and the like, for which constant sup- 
port might be required. 

A- a rule, however, no absolute therapeutic distinction can be 
made, and treatment by exercises and by postures should be 
employed whenever practicable in all cases, whether supports are 
used or not. 

Posture and Exercises. Whatever may have been the original 
cause of the distortion of the -pine and whatever may l>r- it- 



js ( ; ORTHOPEDIC SURGERY. 

it is more marked when the patient is fatigued. Fatigue 
in the Qormal individual is shown by the increase in the normal 
anteroposterior curves ; fatigue in the deformed subject causes an 
increase in the pathological curves. It requires far more mus- 
cular effort to hold the deformed spine in the best possible attitude 
than to hold the normal spine in the correct posture. Motion in 
the normal spine is as free in one direction as in another, and it 
simply requires a proper balancing of the muscular force to hold 
it in the median line. Under the influence of fatigue it has no 
more inclination toward one side than the other unless the occu- 
pation or the attitude of the patient influences it. But when 
there is a fixed deformity, to overcome which, even in part, 
requires the conscious effort of the patient, it is evident that on 
the relaxation of this effort the spine will sink back into the 
habitual posture. The more confirmed the deformity the greater 
must be the effort to overcome it, and the more rapidly will 
fatigue be manifest. Fatigue, or, rather, the relaxation of con- 
scious muscular effort, is favored by attitudes that do not require 
the balancing action of the muscles. For example, the sitting 
posture during school hours favors deformity, while the constant 
alternation of postures in work or play that requires muscular 
activity opposes it. Thus, the selection of occupations, or, at 
least, the restriction of the time passed in inactive postures, is an 
important part of treatment. 

Ajb improper attitudes are favored by weakness of muscles and 
a- tie- maintenance of the best possible position requires a greater 
expenditure of muscular force than is required in the normal 
individual, the strengthening of all the muscles of the body, and 
particularly of those of the back, by gymnastic exercises, even 
beyond the normal standard, is the most important indication in 
tr< atment. 

( me of the most effective systems of treatment of lateral curva- 
ture is that advocati d by Teschner, of New York. On the theory 
that lateral curvature is induced by or that its development is 
favored by a general lack of muscular strength and lack of mus- 
onlar control and co-ordination, Teschner urges the necessity of 
stematic cultivation of all the muscles of the body as well 
as those of the trunk, the part particularly at fault. He also 
insists upon the importance of exercising each muscular group to 
the point of fatigue on the theory that a muscle cannot be 
developed t<. its full capacity unless it is thoroughly fatigued by 
uninterrupted automatic contractions and relaxations. The term 



LATERAL CURVATURE OF THE SPIXE. 



18' 



automatic implies that the patient shall be so thoroughly trained 
in the rhythmical movements that they require no thought for 
their performance. Thus, ease and grace may replace awkward- 
ness and inco-ordination. 

The system advocated by Teschner is modified from one taught 
by Attilla, a " trainer of strong men." It consists of a series of 
exercises with light dumb-bells, and it is followed by so-called 
heavy work. The exercises are designed for systematic cultiva- 
tion of all the muscles of the body, the heavy work more directly 
for the correction of the deformity of the spine. 

General Exercises. The exercises should be performed before 
a mirror, the patient being clad in a close-fitting rowing suit, so 



Fig. 100. 



Fig. 101. 



Fro. 102. 






that the attitudes may be constantly observed by the patient and 
by the instructor. The greatest attention is paid to the perfection 
of the alternating movements of the limbs in order that they may 
become in time purely automatic in character. During the per- 
formance of the exercises the patient holds himself in the besl 
possible position. 

These exercises were described and illustrated by Teschner in 
the Annals of Surgery for August, 1 895, from which they arc 
with his permission, reproduced. 

"A pair of dumb-bells, weighing from one-half to five pounds 
each, according to the ability of the patient, is used in a -< I 
twenty-six exercises. 



- 



( ) R TlinriWIC S URGER Y. 



•• I'm i EXERCISES. The patient stands erect, the heels together, 
the toes apart, the knees thoroughly extended, the abdomen 
retracted, the chest high, the head well poised, and the patient 



Fin 104. 




Fig. 105. 



Fig. 106. 








I"., kin- intently and sharply into his or her own eyes in the 
mirror, the lip- being evenly, but not too firmly, closed, and the 
facial muscles in repose. The pat icnt should breathe easily and 
regularly while exercising | Figs. LOO and 101). 



LATERAL CURVATURE OF THE SPIXE. 



189 



" 1. The upper extremities are fully extended downward, the 
forearms supinated, the elbows remaining elose to the sides of the 



Fig. 107. 



Ftg. 10S. 




Fig. 109. 



Ftg. 110. 




body, and the upper arms being fixed ; the forearms are alternately 
and automatically fully flexed and extended, the wrists and 



I'M) 



ORTHOPEDIC SURGERY. 



entire body being fixed and immovable. Twenty to fifty times 
Fig, LO! 

•• 2, The smic position and exercise, except that the forearms, 
are fully ununited, and remain so during alternate flexion and 
extension. Twenty to fifty times (Fig. 103). 

« :;. Both bells over the shoulders, the arms abducted at right 
angles to the body and in the same vertical and horizontal planes, 
the forearms fully Hexed upon the arms, and the wrists fully 
flexed upon the forearms. The forearms and wrists are then 
alternately and automatically extended and flexed. Ten to 
twenty times (Fig. 104). 



Fig. 111. 



Fig. 112. 




• 1. The same position and exercise, except that both upper 
extremities are flexed and extended at the same time. Five to 
fifteen times I Fig. L05). 

Both upper extremities fully extended forward on a level 
with the shoulders, the dorsum of the hands outward. They are 
tie ii fully and forcibly abdueted on a horizontal plane, the patient 
;it the same time raising the body upon the toes, and are then 
permitted to recede to the original position, the body resting on 
tie- toes and beelfl, the elbow- and wrists still rigid, the bells 
not b« iie_ r permitted to touch a- they approximate each other. 
Five to ten tine- i Figs. L06 and 1<»7 ). 

Bells in the position of exercises No. 3 and No. 4. The 



LATERAL CUEVATUEE OF THE SEISE. 



191 



arms are fully extended alternately above the head. Ten to 
twenty times (Fig. 108). 

" 7. Bells in front of the thighs, forearms pronated, and bells 
alternately raised to the level of the shoulders, the elbows and 
wrists being lixed. Ten to twenty times (Fig. 109). 

" 8. The arms abducted at right angles to the body, the bells 
rotated rapidly and forcibly forward and backward, the elbows 
being fixed. Five to ten times (Fig. 110). 

" 9. The arms abducted at right angles to the body, the thumbs 
upon one ball of each bell, the hands circumducted forward from 



Fig. 113. 



Fig. 114. 



Fig. 115. 




above downward, the ball upon which the thumbs reel describing 
circles, the elbows and shoulders being fixed. Five to ten times 
Fig. 111). 

" 10. The same as Xo. 9, the hands being circumducted back- 
ward. Five to ten times (Fig. 111). 

"11. The bells to the side Right face upon left heel, then 
placing the foot at right angles to right foot opposite the arch, 
the knees -lightly flexed, the right hand at waist-line againsl 
the body, the bell being perpendicular. Second part of motion: 
strike from the shoulder to level of the fare, advancing a 



192 



ORTHOPEDIC SURGERY. 






extending the right thigh and 



leg, the 



upon the left foot, rapidlj 

pighl foot being fixed upon the floor, and quickly back to position. 

1\ 11 to fifteen times I Figs. 1 L2 and 113). 

" 12. Exactly the reverse of No. 11. Ten to fifteen times. 

u 1"». Bells extending above the head, palmar surfaces looking 
forward, bending down to the floor, the knees remaining extended, 
and return. Five to fifteen times (Figs. 114 and 115). 

"14. Bells downward at the sides, raising and dropping the 
shoulders. Ten to twenty times (Fig- 116). 

" L5. Bells downward at the sides, flexing the spine laterally, 
first to the right and then to the left. Ten to twenty times 
Fig. 117). 



Fig. 116. 



Fig. 117. 





" 1,; - Both arms are extended forward to about forty-five 
- and abducted at about the same angle, then forcibly 
1 in front of the chest, causing the pectoral muscles to con- 
trad vigorously, the elbows and wrists being fixed, and then back 
to the original position. Five to twenty times, alternating the 
right and left bands above (Fig. 118). 

"17. Bells at the Bides, palmar surfaces looking forward. 

ad arms backward in a vertical plane as forcibly as possible, 

holding them rigid in the fully extended position for a few 

moments, and then returning the bells to the sides. Five to 

Figs. 119 and 120). 



LATERAL CURVATURE OF THE SPIXE. 



193 



"18. Bells to the sides. Raise the body upon the toes aud 
sink to the original position. Ten to twenty times (Fig. 121). 



Fig. IIS. 



Fig. 119. 




Fig. 120. 



Fig. 121. 





u 19. Same position. Raise the toes as far as possible from 
the floor, the body remaining erect. Ten to twenty times ( Fig. 
122). 

13 



L<M 



ORTHOPEDIC SURGKIiY. 



- 20. Same position. The patient squats, abducting the knees 
and resting upon the toes, the heels being raised, the trunk per- 
fectly erect, then resuming first position. Five to twenty times 
Fi*. 123). 






Fig. 123. 





Fig. 124. 



Fig. 125. 





"21. Same position. Standing upon left foot. Flexing the 
thigh to a right angle to the body, extending the knee and 



LATERAL CURVATURE OF THE SPISE. 



195 



ankle fully. The patient squats on the left ham, the left heel 
remaining on the floor, and then resumes the first position. Two 
to live times (Fig. 1'24). 

" 22. The same standing upon the right foot. Two to five 
times. 

Fig. 126. Fig. 127. 

1% 




" 2-3. The same position. Alternately and forcibly flexing the 
thighs and legs, causing the knees to touch the shoulders. Ten 
to twenty times (Fig. 125). 



Fig. 128. 




" 24. The same position as in No. 21, extending the righl 
lower extremity, the right bell inside the thigh, the right foot 
moved in a circle on a horizontal plane to complete extension 
backward, and resuming the first position. Two to five times 

■ Figs. 12') and 127). 



L96 



ORTHOPEDIC SURGERY. 



Two 



« 25, The Bame as No. 2 I, standing upon the right foot. 
to five times I Figs. 126 and 127). 

"26. The patient lying supine upon the floor, the lower 
extremities fully extended, the bells resting upon the chest, then 
raisin- the trunk to the sitting position, the lower extremities 
remaining extended, and the eyes being fixed upon the ceiling, 



Fig. 129. 




an advanced type accompanied by dyspnoea and cyanosis. (Teschner.) 

and returning to the original position, touching the back of the 
head only on the floor; thus the hyperextension of the spine is 
maintained. Five to twenty times (Fig. 128)." 

I consider these floor exercises especially useful, and, in prac- 
tice, add several others to those described by Teschner, viz.: 
27. The patient lying as in Fig. 128, lifts each fully extended 
ilternately a distance of about two feet from the floor, then 
- -lowly sink to it- original position. Ten times. 



LATERAL CURVATURE OF THE SPINE. 197 

28. Both limbs together. Five times. 

29. The patient lying extended in the prone position, places 
the palms of the hands on the hips and "looks at the ceiling/' 
overextends the spine as much as possible, then sinks slowly to 
the original position. 

Fin. 130. 




The same patient swinging 30-pound bell, showing the muscular development. (Teschner. 1 

30. Each leg fully extended is lifted upward alternately aa far 
as possible (hyperextension at the hips). Ten times. 

31. Hyperextension at both hips simultaneously if possible. 
Five times. 

"When the patient has become proficient in these exercises, 
they should be done at home every morning and evening. 



L98 



ORTHOPEDIC SURGERY. 



"Tiik HEAVY WOBK. Bells, weighing from five to eighty 
pounds each, and steel bars and bar-bells, weighing from twenty- 
Mi to over one hundred and eleven pounds, are used in different 
ways* Bells are pushed from the shoulders above the head alter- 
nately as often as the patient is able (Figs. 131 and 132). 



Fig. 131. 



Fig. 132. 




i be patient pushing 25-ponnd bells 
the right arm up. (Tescbner.) 



The patient pushing 25-pound bells 
the left arm up. (Teschner.) 



"The patient is instructed to swing a heavy bell with one 
hand from the floor above the head and down again, the elbow 
and tin- wrist being fixed, and the motion repeated as often as 
possible in a systematic manner; then with the other hand the 
Bame Dumber of times and later with both. This exerts all the 
extensor muscles from the toes to the head in rapid succession. 



LATERAL CURVATURE OF THE SP1XE. 199 

(For this exercise the patient stands firmly, with the legs 
astride of the heavy bell, and then, bending over, he seizes it 
and throws the extended arm upward entirely by the action of 
the back muscles. The bell is poised for a moment above the 
head, and it is then swung downward, carrying the extended arm 
between and behind the legs.) 

" When a heavy bell is pushed or swung above the head on 
the side opposite the scoliosis, the action cf the back muscles, to 
sustain the weight and equilibrium, is such as to cause the curved 
spine to approximate a straight line (Fig. 132). A similar result 
is produced when a heavy weight is held by the side of the erect 
body on the scoliotic side, the arm being at full length. 

•• When a heavy bar is raised above the head with both hands 
the patient must fix the eyes upon the middle of the bar to main- 
tain an equilibrium. This necessitates the bending of the head 
backward, the straightening and hyperextending of the spine, 
and consequently correcting a faulty position with a weight super- 
imposed. The heavier the weight put above the head, whether 
with one hand or with two, the more the patient must exert 
himself or herself to attain and maintain a correct or an im- 
proved attitude in order to sustain the equilibrium. (By an 
improved attitude I mean the greatest amount of correction of 
the deviation of the spine that the fixation of a deformity will 
allow of.) Hence, the greater the weight, the more forcible the 
actions of the muscles become, and the greater the temporary 
reduction of a deformity. It is by means of frequent and 
forcible temporary reductions of deformities, by voluntary mus- 
cular action, that we can hope to improve, and do improve, those 
cases which are amenable to any form of active treatment. 

"When a patient, lying supine upon the floor, raises a heavy 
bar above the head so that the arms are perpendicular to the 
floor, the weight of the bar, the position and weight of the body, 
and the action of the muscles tend to broaden the entire back 
and shoulders, and a slow downward movement tends to widen 
the entire chest, and most markedly at the shoulders. The fre- 
quent repetition of the upward and downward movements plays 
an important part in the rapid development of the chest and 
back. Pushing the bells above the head, swinging them with 
each hand separately and with both hands together, raising a bar 
above the head, standing and lying down, and tin- exercises 
before enumerated, constitute one day's work. 

"As the amount of work performed by a patient depends 



•_'< H I 



ORTIIOPKDIC sriWURY. 



upon the last previous record of that patient, that record must be 
improved upon at eaeli succeeding visit, unless there be a good 
reason to the contrary. Most patients can well stand three 
treatments a week (vide table). In mild, habitual cases im- 
provement in deportment is noticed by the patient's relatives 
and friends and by the patients themselves within the first two 
week-. In these eases two months' treatment usually suffices to 
effect a 'complete' cure. In the more severe cases such rapid 
results cannot be expected, but a certain appreciable improvement 
is effected, and the amount of improvement depends upon the 
persistent continuance of the treatment. When there is fixed 
rotation of long standing, with bony and ligamentous changes, 
the prospects are not so good ; but even in those cases consid- 
erable improvement will be evident." 

" Patients are not permitted to wear supports of any kind, not 
»ven corsets. They should not exercise until at least two hours 
after a meal, nor when menstruating. The general health is 
improved by the exercises; the patients gain in height and 
weight. The girth and breadth measurements, chest depth, 
strength tests, and lung capacity are generally increased, and the 
depth of the abdomen is usually decreased. In some cases, es- 
pecially those of undersized patients, the increase in height is 
very rapid, and it is certainly more than the increase by ordinary 
growth. There were marked cases of flat foot which were bene- 
fited. The flat feet became shorter through the exercises by the 
increase in depth of the inner arches." 

Record of the Work Performed by a Girl Fourteen Years 
of Age (Teschner). 





Regu- 
lar 


Pushing 


Swinging 
with each 


Swinging 
with both 
hands two 
15-ib.bells. 


Pushing 

two 20-lb. 

bells. 


50-lb. bar above the 
head. 




two 10-lb. 
bells. 


hand one 
15-lb. bell, 
right t<> left 




Standing. J** 


[>ril «"- 


















100 


10-10 


5 




Instructed. 


Instructed. 


• 11 




150 
2 IMb.bell? 


I 20-lb. bell 


15 


S 


2 


5 


•' 13 


" 


50 


25-25 


25 


12 


5 


10 




" 


54 


30-30 


35 


18 


7 


12 






60 


1 2.Vlb. hell 


-10 
2 20-lb.bells 


20 


7 


15 






7d 


20-20 


20 


30 


10 


15 








11-22 




33 


15 


16 




•' 


100 




30 


50 


17 


20 






110 




x.:, 


60 


20 


22 






120 






70 


20 


25 








i 80-lb. bell 




2 25 lb. bells 


64-lb. bar 


64-lb. bar 






140 


20-20 


in 


25 


5 


10 




" 


150 




45 


30 


7 


12 


• 11 




160 


27-27 


:,ii 


34 


9 


13 


" 16 




170 


80-30 


55 


40 


10 14 



LATERAL CURVATURE OF THE SPINE. 9()l 

This system of exercises combines the forcible correction of 
deformity and the overcoming of restriction of normal motion by 
means of the " heavy work " with muscle building. It has the 
merit also of making an immediate mental impression upon the 
patient which no other system can make ; for if the patient does 
not " strain every nerve " he must certainly exercise every muscle 
to preserve the equilibrium while supporting the heavy weights, 
and this mental impression is, undoubtedly, one of the important 
elements in successful treatment. 

The system has the disadvantage, if disadvantage it may be 
called, of making class work impossible, for the patient must be 
under constant supervision, not only that he may be urged to 
the limit of his capacity, but that overstrain may be avoided as 
well. 

It might appear from the description that the danger of over- 
work is great, but in a long series of cases, some of which were 
complicated by defects of the heart and lungs, no unfavorable 
symptoms have been observed by Teschner. The system is, 
however, one that can only be practised by a physician. 

Another system of exercises, modified somewhat from the 
so-called Swedish system, more suitable for class work is that 
followed at the Hospital for Ruptured and Crippled. Dr. 
Truslow has been kind enough to outline for me some of the 
more important exercises, and to illustrate them with the photo- 
graphs that are reproduced here. 

The objects of the treatment are: (1) To overcome the 
patient's faulty habits of posture by the repeated purposeful 
assumption of proper postures ; in other words, to counteract the 
deformity habit by training the mental and muscular perception 
of symmetrv. (2) To stimulate and to strengthen the weakened 
muscles, particularly those muscular groups that are especially 
concerned in overcoming the deformities, and which, for the 
present purpose, may be considered as weak. 

For convenience of description the exercises are divided into 
two classes : (1) self-correction ; (2) muscle building. 

Self-correction, Postures. The first exercises (a and h) in self- 
correction are for the purpose of overcoming the anteroposterior 
deformities that usually accompany lateral deviation <>f tin- 
spine. 

Head Bending Backward, in this exercise the chin is 
not tilted upward, but, the head being held level, the n<'<'l< is 
drawn directly backward until the cervical and upper part of the 



202 ORTHOPEDIC SUROERY. 

doreal segments of the spine are completely extended. Thus, 
by increasing the distance between the points of attachment of 
the sternomastoids and the sealeni, strong traction is made upon 
these muscles with the effect of elevating the upper part of the 
thorax — an important feature in the exercise. 

(6) Trunk Bending Forward and Trunk Kaising. The 
patient stands in the erect posture with the spine extended and 
the chest expanded as in the previous exercise. The trunk is 
then bent forward (similar to Fig. 138), the only motion being 
at the hip-joints. The trunk is then raised again to the former 
l> sition, oare being taken to keep the hips farther back than the 
chest. In both flexion and extension the spine must be rigidly 
held in the corrected attitude, and there must be no motion at the 
knns There is, of course, a movement corresponding to exten- 
sion at the ankle-joints when the legs and buttocks are thrown 
backward to compensate for the forward bending of the body. 
The object of this exercise is to train the patient to keep the hips 
back and the chest forward. 

The other exercises in self-correction are for the purpose of 
overcoming lateral deviation of the spine, the right dorsal, left 
lumbar curve being taken as the type (Fig. 133). 

This series is arranged in a progression, and each one must be 
Learned before the next in order is attempted. 

(c) Left Neck Firm. The left hand is placed behind the 
neck, the left shoulder is raised, and the left elbow is held well 
back. This posture impresses upon the patient the necessity of 
approximating the left shoulder and the neck (Fig. 134). 

(a*) Body Inclination to the Left. This is a most impor- 
tant posture; it is intended to correct mechanically the faulty 
inclination to the right and to overcome the upper curve by trac- 
tion on its concavity. The patient holding the arm in the first 
position is instructed to stretch well out with the left elbow, 
rotating upward and abducting the left scapula as much as pos- 
sible. This puts upon the stretch the rhomboidei and the lower 
half of the trapezius of the left side, thus making strong traction 
upon their point- of attachment in the dorsal concavity. At the 
same time the patient is directed to sway the pelvis to the right. 
This usually requires assistance at first, for it brings into action 
certain deep back muscles, over which one has ordinarily but 
little control The shoulder- must be kept level and the proper 
relation of the head and neck to the left shoulder must not be 
disturbed in this forced stretch to the left (Fig. 135). 



LATERAL CURVATURE OF THE SPIXE. 



203 



(e) Chest Pressing with the Right Hand. The patient 
holding the left arm in the first position presses the right hand 
firmly against the dorsal convexity. This posture may be em- 



Fio. 133. 




Typical lateral curvature. Right dorsal. Left lumbar. 



204 



ORTHOPEDIC SURGERY. 



ployed to advantage if there is a long right dorsal curve, when it is 
an efficient aid to the left-sided pull of the two former exercises. 
(/) Right Neck Firm. The right hand is placed behind the 
Deck, without, however, disturbing the improved position induced 
by the first exercises. With both hands placed behind the head, 



Fig. 134. 




Left neck firm. 

the anna being in a symmetrical position, there is better mechani- 
cal fixation of the head, neck, and upper part of the trunk during 
the next exercise < Fig. 136). 

((j) Left IIii» Twisting Backward. In posture (d) the 
pelvis was -waved slightly to the right; it is now twisted slightly 



LATERAL CURVATURE OF THE SPINE. 



205 



backward on the left side to overcome the twist in the lumbar 
spine which usually throws this side of the pelvis somewhat for- 
ward. This correcting motion should be carried out in the lower 
dorsal and lumbar segments, and it should not affect the attitude 
of the remainder of the trunk. 

Fig. 135. 




Body inclination to the left. 



(A) Left Oblique Stbide Standing. The pelvic twist and 

right-sided sway being rigidly maintained, the left foot is placed 
about two foot-lengths forward and a little outward. Upon this 
leg the greater part of the weight of the body ifl now supported. 
This allow- n Blight downward tilt of the pelvis to the right, and 
lessens the left lumbar convexity (Fig. 137). The positions, 



206 



ORTHOPEDIC SURGERY. 



attained by the progressive exercises to tills point, being main- 
tained, the patient continues with 

(/) Trunk Bending Forward. In this posture, motion takes 
place in the hip-joints only, as in the first exercise. This exer- 
cise further emphasizes the symmetrical position of the head and 
neck, the left-sided inclination of the upper half of the trunk, 
the right-sided inclination of the lower half, the twist and down- 



Fig. 1:56. 




Right neck tinn. 



ward tilt of the pelvis | Fig, 138). The return to the improved 
standing position should be made in this order: (1) trunk raising; 
2 replacement of the left foot; (3) return of both arms to the 
sides. Tlii- is done -lowly and carefully by the patient, who 
attempts to maintain the improved posture. 

Tic- postures constitute a progression which cannot be learned 
in less than seven treatments ; often much more time is required. 



LATERAL CURVATURE OF THE SPINE. 207 

As each part is learned it should be practised at home until the 
next treatment, when a new posture is added, if it appears that 
progress can be made. 

Fig. 137. 




Left oblique stride standing. 



208 



ORTHOPEDIC SU1WER Y. 



These successive postures are in reality exercises in that it 
requires constant muscular effort to retain them, but they are not 
exercises in the sense of repeated alternations of position. The 
series is simply an elaboration of what is called the keynote 



Fig. 138. 




Trunk bending forward. 



posture. The raising of the left elbow, for example, makes it 
easier for the patient to overcome the distortion of the upper part 
<»f the -pine ; it also instructs him in the manner of holding the 
-pin.' in tie- improved position after the arm is placed by the side. 



LATERAL CURVATURE OF THE SPINE. 209 

The same is true of all the postures ; each one suggests and makes 
correction easier, and after sufficient practice the patient should 
be able to assume the corrected position without placing the arm 
or the leg in the preliminary attitude. Thus the successive 
postures are, as it were, letters, which, placed together one by 
one, make a complete word, or the best possible position that the 
patient can assume. At first the patient must use the letters and 
slowly spell out the corrected attitude, but after the muscles have 
been educated by the repeated assumption of each posture, and 
when the perception of symmetry has been acquired, the corrected 
attitude may be assumed at will. Finally, the improved posture 
will be instinctively retained, and will become habitual. 

Muscle Building Exercises. In the treatment of lateral curvature 
one aims to strengthen : 

1. The posterior cervical muscles. 

2. The dorsal and lumbar muscles. 

3. The muscles of vertebroscapular attachment. 

4. The abdominal muscles. 

5. The thigh and leg muscles. 

6. The chest-expanding muscles. 

The following exercises have been selected as best adapted for 
this purpose. Each one should be performed five or more times 
according to the strength of the patient. 

(a) Opposite Standing, Head Bending Backward, Re- 
sisted. The patient stands before a wall or a shoulder-high hori- 
zontal bar, ou which the hands are placed with the arms extended. 
The head is bent forward, and is then forced backward, tfre latter 
movement being resisted by the hand of the surgeon. This 
exercise is desigued to strengthen the posterior cervical muscles. 

(b) Opposite Bend Standing, Trunk Raising, Ivkststed. 
The patient stands with the upper part of the thighs in contact 
with a table or horizontal bar. The hands are placed behind the 
neck and the body is bent forward on the hip-joints as in the 
first exercise. The surgeon, standing behind, places his right 
hand over the posterior dorsal prominence and his left over the 
lumbar projection. The patient then raises the trunk to the erect 
position against the combined resistance (Fig. 139). With a 
little practice the surgeon learns to give an outward twisting 
motion to his hands while resisting, which tends to untwist the 
spinal rotations. When the dorsal rotation to the right is marked 
this untwisting may be facilitated by encircling the patient'- <•! 
with the left hand, while with the ri;_d)t strong forward and ont- 

14 



210 



ORTHOPEDIC SVllOERY. 



ward pressure is made as the patient raises the body. This exer- 
cise is for the purpose of developing the muscles of the erector 
Bpinse group. 



Fig. 139. 




Opposite bend standing," trunk raising, resisted. 



Prone Lying, Head and Shoulder Raising "the 
SEAL." The patient lies upon a table or upon the floor, and 
raises the head and chest — "looks at the ceiling." Progression 
is made in tin- increased leverage of arm-weight transference. 



LATERAL CURVATURE OF THE SPINE. 



211 




212 ORTHOPEDIC SURGERY. 

1. With the hands on the backs of the thighs. 
'1. With the left hand behind the neck and the right hand on 
the back of the thigh. 

3. With both hands behind the neck, and with the elbows 
well out and back. 

4. "Swimming." The arm motions of swimming, in three 
counts. This exercise is to strengthen the muscles of the back 
from the head to the pelvis. 

(il) Prone Lying, " Diving." The patient lies upon a 
table, the trunk and pelvis projecting beyond its edge, the limbs 
being fixed by a strap or by the weight of another person. The 
body is then bent downward and is raised again to the horizontal 
position (Fig. 140). In this exercise assistance will be required 
at first. Progression is made by transference of arm weights, as 
in the former exercise, thus : 

1. With the hands on the hips. 

2. With the arms stretched out at right angles to the body. 

3. With the hands behind the neck. 

4. With the arms extended in the line of the body. 

This exercise is for the purpose of strengthening all the mus- 
cles of the back. 

(e) Prone Lying, Leg Kaising. The patient, lying in the 
prone posture upon the floor or table, lifts the limbs (overextends) 
alternately, the raised leg held perfectly straight. When the left 
thigh is extended, as much as the iliofemoral ligament will allow, 
the left side of the pelvis is tilted upward also, thus untwisting 
the Lumbar spine. Progression in this exercise is made as follows : 

1. Alternate leg raising, unresisted. 

2. Alternate leg raising, resisted. 

.'). The leg motions of swimming, in three counts. 

In this exercise the entire lower extremities must project 
beyond the supporting table. The exercises are for the purpose of 
strengthening the lumbar muscles and the extensors of the thigh. 

(/) ( Opposite Sitting, Backward Bending of the Trunk. 
'Hie patient is seated upon a bench, and the feet are fastened to 
the floor. The trunk being held in a position of complete exten- 
sion, i- bent -lowly backward, motion being at the hip-joint only. 
Progression. 

1. With the hands behind the hips. 

2. With theleft hand behind the neck, the right hand on the hip. 
• I. With both hands behind the neck. 

1. With both arms extended upward. 






LA TEE A L C UE VA T UEE OF THE SPIXE. 2 1 3 

At first the bodv is bent backward about forty-five degree?, 
later until the head touches the floor. This exercise is to 
strengthen the abdominal muscles. 

(g) The Horizontal Bar. " Pull-ups. " The patient 
hangs by the hands and is assisted to " chin the bar." The body 
is then allowed to sink slowly back into the former position, the 
elbows are held well back, and the patient is instructed to bear 
as much of the weight as is possible with the left arm and 
shoulder. This exercise corrects the dorsal curve by means of 
muscular activity, and the lumbar curve by the weight of the 
suspended pelvis and limbs. The muscles used are those with 
vertebroscapula attachment. 

(h) Left Leg Standing, Pelvis Tilting. The patient 
stands upon the edge of a bench, supporting the weight on the 
left leg, the right leg being suspended beyond the side of the 
bench. While the head and trunk are kept in the corrected 
position, the pelvis is made to tilt sharply downward on the right, 
by lowering the right leg, while the left is kept perfectly stiff. 
This has the effect of straightening the lumbar curve. 

(i) Left Leg "Hopping." Both hands are placed behind 
the neck and the weight is supported entirely upon the ball of 
the left foot. In this attitude the patient hops ten or more times. 
This exercise, like the last, tends to straighten the spine and to 
strengthen the muscles of the left leg, which are often somewhat 
weakened from disuse. 

(j) Respiratory, Half Reclining, Arm Extensions and 
Flexions, Resisted. The patient sits in a chair with an inclined 
back, or lies upon a low table with hard pillows under the mid- 
dorsal region, so that the upper dorsal and cervical segments of 
the spine must be overextended. The arms are stretched upward 
and backward, and the hands are grasped by the surgeon, who 
stands behind and resists the patient's downward pull. With the 
upward stretch of the arms and pull by the surgeon the patient 
inhales forcibly. With the downward pull against resistance, 
the patient exhales forcibly. This exercise is made in the rhythm 
of -low breathing. 

When the patient has been thoroughly instructed in eelf- 
correction and in the exercises for muscle building, general 
L r yninastics for systematic motor training may be given effectively 
t<» groups of fifteen or twenty pupils. 

The exercises illustrated on pages 187-195 will serve this 
purpose satisfactorily. 



21 } ORTHOPEDIC SURGERY. 

These two systems of treatment by gymnastics have been 
selected as the most practicable of the many that have been 
devised. It may be stated that any treatment that makes the 
spine more flexible, that overcomes faulty attitudes, and that 
strengthens the muscles, must be of benefit to the patient, the 
degree of benefit corresponding to the persistence and energy of 
the pupil and the instructor rather than to any particular theory 
on which such treatment is based. The rotation of the vertebral 
bodies is Increased by forward bending of the trunk, and, as this 
is the more important element of lateral curvature, it is evident 
that extension or overextension of the spine, combined with lateral 
twisting in such a manner as to reverse the habitual inclination, 
will most directly lessen or correct the distortion. If improvised 
exercises are conducted from this standpoint they will always be 
effective. 

The Removal of Superincumbent Weight. The removal of super- 
incumbent weight by the assumption of the reclining posture 
whenever the patient is fatigued is an important adjunct in the 
treatment of a certain class of cases. The patient should lie, 
preferably, upon a hard support in the supine posture, with the 
arms extended above the head. If the dorsal kyphosis is exag- 
gerated, a firm cushion between the shoulders or under the 
projecting ribs will aid to expansion of the chest and favor the 
correction of the deformity. 

Si;lf-suspexsiox. Self-suspension, by means of the halter 
and pulley, is of service in overcoming secondary contractions of 
the tissues, and thus it aids in the correction of deformity. It 
is often efficacious, also, in relieving the discomfort that is some- 
Tim, is a troublesome symptom when the distortion is extreme. 
While the patient is suspended forcible manual correction of the 
deformity can be applied to advantage. 

Suspension from the horizontal bar acts in a similar manner, 
although it is less effective than when the traction is made upon 
the entire -pine. In this form of suspension the bar should be 
oblique in direction, the high side for the low shoulder. Thus, 
a passive "keynote" is induced while the patient is suspended. 
Exercises in this position, for example, flexion, extension, and 
abduction of the thighs, swaying the trunk from side to side, 
" chinning " the bar, and the like, are useful. 

The Use of Braces or Other Supports. In the treatment of the 
ordinary type of lateral curvature, when there is an opportunity 
for proper gymnastic training, direct support is not usually 



LATEEAL CURVATURE OF THE SPISE. 



215 



indicated. There are, however, cases even in this class in which 
the deformity habit is so persistent, and in which the voluntary 
efforts of the patient to assume a better attitude are so ineffective, 
that support may be employed for a time with advantage. 



Fig. 141. 



Fig. 142. 





Sell-suspension, illustrating the effect of traction in lessening deformity Induced by 
paralysis. (Gibney.) In such cases support is essential. 

The best support is a plaster corset applied with as much manual 
corrective force as is practicable while the patient is suspended in 

the upright posture if lateral deviation Is most marked or if the 



216 ORTHOPEDIC SUBQEET. 

curvature is flexible; in the horizontal preferably if the rotation 
la the prominent feature of the deformity. 

If correction is attempted in the horizontal attitude the patient 
may be suspended in the prone posture on a strip of cotton cloth 
(the hammock method). As this sinks under the weight of the 
trunk, it falls into the attitude of overextension, which is that 
most favorable for the untwisting of the rotated spine. When 
the deformity is marked, the body may be suspended in the 
lateral attitude by means of a sling of cotton cloth passed about 
the prominent ribs ; thus the weight of the body acts as a cor- 
recting force during the application of the corset. 

In using such corrective force one endeavors, if possible, to 
overcorrect the habitual deformity and the less marked changes in 
the anteroposterior contour as well. For example, if the lumbar 
region is flat one attempts to reproduce the normal lordosis, and 
if the body is habitually inclined in one direction one endeavors 
to Bway it to the opposite side, and to efface the so-called high hip. 

This attitude of overcorrection assured by the corset, combined 
with exercises, is especially efficacious from the curative stand- 
point in the treatment of single flexible curves. If the second or 
compensatory curvature has already appeared, one attempts to 
overcorrect the primary deformity and directs exercises for the 
purpose of straightening the second curve while the patient is 
wearing the corrective corset. For as the compensatory curva- 
ture is usually in the dorsal region, it may be considerably influ- 
enced by postures of the arms and shoulders. As often as pos- 
sible during the day the patient should endeavor to improve upon 
the attitude which the corset enforces, by assuming the keynote 
position and by flexing and extending the trunk on the hips. 
For general exercises the corset may be removed, and, as a rule, 
it need not be worn at night, although in the treatment of young 
subjects it- constant use for one or more weeks is of service in 
enforcing a proper attitude. 

When the deformity is dependent upon irremediable injury or 
je, such, for example, as anterior poliomyelitis or empyema, 
some form of brace must be employed constantly to prevent exces- 
sive lateral deviation of the trunk ; and in cases of fixed deformity 
in older Bubjects, especially if the patient's occupation is fatiguing, 
a support may he indicated to relieve symptoms of discomfort or 
pain. 

Support i- employed primarily with the aim of preventing an 
increase <>f deformity and to relieve symptoms incidental to the 



LATERAL CURVATURE OF THE SPIXE. 



217 



deformity. It may serve, also, in some degree as a corrective 
appliance. If it holds the spine in the extended position or 
induces lordosis, it may, by relieving the anterior portion of the 
column in part from the deforming influence of superincumbent 
weight, induce or permit a slight lessening of the rotation of the 
vertebral bodies. On this principle a light steel brace after the 
Taylor model may be as effective as any of the more complicated 
appliances, as was suggested many years ago by Judson. Corsets 
of other material than plaster, for example, of paper, or of alumi- 
num, as suggested by Phelps, may be employed when the 
deformity is fixed and when no change in the position or size of 



Fig. 143. 




The Knight spinal brace, as used in lateral curvature. A leather or canvas band, made 
adjustable by lacings, is stretched from the posterior upright to the side bar on the side of 
the dorsal convexity. 

the trunk is to be expected. The Knight brace, when carefully 
adjusted, appears to meet the requirements fairly well, and when 
Less -upport is needed an ordinary corset strengthened by light 
steels may be sufficient. 

Forcible Correction of Deformity. In the treatment by gymnas- 
tic exercises the patients are supposed to overcome by voluntary 
effort, as far as is possible, the secondary accommodative contrac- 
tions of the soft parts that prevent the correction of the deformity, 
the heavy work of the Teschner system being particularly effec- 
tive for this purpose. J>ut in many instances the voluntary cor- 
rection of deformity may be supplemented with advantage by the 



2 1 8 



uimiui>i<:i)H< sui:a/<:nY. 



Fig. 144. 



employment of force. For example, the patient may use the 
weight of the body as a means of correction by forcibly flexing 
the trunk over a padded bar (Fig. 149) and a variety of similar 
postures, either active or passive, with or without suspension, 
may be utilized with the same object. Corrective force applied 
by the hands, the patient's trunk being flexed and rotated in the 

directions opposed to the de- 
formities, although the most 
effective method, is the most 
fatiguing, and machines have 
been constructed with the aim 
of applying the force in a simi- 
lar manner. This is illustrated 
by the appliance of Hoffa, 
which has been modified by 
Schede and others. In this ma- 
chine the patient is suspended, 
the hips are fixed, and the press- 
ure screws are applied upon 
the convexities of the double 
curve, with the aim of untwist- 
ing the spine. The correction 
is maintained for fifteen min- 
utes or longer, and it is then 
followed by the regular exer- 
cises of the day (Fig. 144). 

The Forcible Correction of De- 
formity Combined with Fixation. 
Forcible correction and fixa- 
tion is the treatment of selec- 
tion for resistant lateral curva- 
ture in early childhood, because 
one cannot command the co- 
operation of the patient in 
maintaining the proper attitude, 
and because the rapid growth at this age, which favors the in- 
crease of the deformity, is equally favorable to its cure if the 
Btatic conditions can be changed. 

For example, one treats the severe rhachitic kyphosis of infancy 
by fixation on the stretcher frame in the attitude of overexten- 
sion, and by daily manual correction of the deformity. And in 
the treatment of older children, in whom posterior or lateral 




Forcible correction by means of the modi- 
fied Hoffa appliance. (Bradford and Brack- 
en.) 



LATERAL CURVATURE OF THE SPIXE. 219 

deformity is fixed, one is justified in using the same method for 
its relief and cure that would be employed in the treatment of 
Pott's disease. In this class the plaster-of-Paris jacket, applied 
while the trunk is held in the best possible position, is the treat- 
ment of selection — a treatment that should be continued until the 
deformity is cured or until further rectification by this meaus is 
found to be impossible. 

The most conyenient method of applying the jacket is by means 
of the ordinary suspension apparatus. The back having been 
carefully padded at the points of pressure, the patient is sus- 
pended, and while traction and manual correctiye force are 

LUC curwa > v- . 

The High Shoe. The same object may be attained in the 
erect posture by the use of a higher heel, or heel and sole. The 
elevation may be from a half -inch to an inch and a quarter, the 
amount being regulated by its effect upon the contour of the 
trunk. 

Posture and Support during Eecumbexcy. The atti- 
tudes habitually assumed during recumbency should be investi- 
gated. The bed should be provided with a hard mattress and a 
low pillow, and the patient should be encouraged to lie habitually 
upon the side which opposes the deformity, or upon the back. 
The rectification induced by such an attitude may be still further 
increased by the use of a hard pillow beneath the convexity or 
beneath the back, and iu certain instances the Barwell sling may 
be employed with advantage. 

General Treatment. The importance of improving the gen- 
ial condition of the patient by regulation of the diet, by cold 

exerted the plaster bandages are applied. In this correction two 
points are of especial importance : to attain as much extension or 
overcorrection as possible, and to sway the entire body in the 
direction opposite to the habitual inclination. By overextension 
one removes the weight in part from the vertebral bodies that 
are primarily deformed, and by lateral correction one endeavor- 
to change the relation of the weight to the distorted part. This 
improved position must be carefully maintained by the hands 
until the plaster bandages have become firm. The jackets may 
be changed at intervals of about a month, and at each applica- 
tion one attempts to improve upon the former position. 

Lovett 1 has nrged the importance of correcting anteroposterior 

: Transactions American Orthopedic Association, 1901, vol. xiv. 



220 



ORTHOPEDIC SVROERY. 



deformities by straightening the compensatory curves. For 
example, if a dorsal convexity is accompanied by a lumbar con- 
cavity the jacket should be applied while the lumbar segment is 
Straight. This may be accomplished by supporting the trunk in 
the prone posture on a hammock, the legs hanging downward on 
either side, or in the sitting posture. The effect of flexion of 
the thighs in straightening the lumbar spine is illustrated in 
Fig. L45. Theoretically, if this attitude persists, it should 
induce a flattening of the abnormal kyphosis of which the lor- 
dosis is the effect, particularly if the improved position is favored 
by appropriate postures and exercises. 

: \}c a^y^ i\^Yxi£ loicVm ffSfikr- 

lar manner. This is illustrated 
by the appliance of Hoffa, 
which has been modified by 
Schede and others. In this ma- 
chine the patient is suspended, 
the hips are fixed, and the press- 
ure screws are ; applied upon 
the convexities of the double 
curve, with the aim of untwist- 
ing the spine. The correction 
is maintained for fifteen min- 
utes or longer, and it is then 
followed by the regular exer- 
cises of the day (Fig. 144). 

The Forcible Correction of De- 
formity Combined with Fixation. 
certain instances one is able to correct the deformity more effect- 
ually by horizontal than by vertical suspension in the manner 
already described. 

When the deformity has been overcome, or when the contin- 
uation of the treatment seems undesirable, the jacket may be 
r< placed by a corset, which may be removed for daily massage and 
for exercises. This may be finally discarded when the muscular 
strength has beeo regained. 

A.8 has been stated, forcible correction and fixation is essen- 
tially a treatment of deformity in early childhood. But in cer- 
tain instances, when, for example, the deformity is extreme or is 
increasing rapidly, it may be employed in adolescence. In the 
treatment of this class of cases the plaster jacket is usually 
applied while the patient is fixed in the best possible position by 




LATERAL CURVATURE OF THE SPINE. 221 

means of some form of pressure apparatus, as is illustrated in 
Fig. 144. 

Forcible correction of deformity in this manner, uuder anaes- 
thesia, with subsequent fixation of the trunk and of the head, if 
possible, in the overcorrected position, is advocated by Wnllstein, 1 
and it may be of service in certain cases. 

The Yolkmanx Seat. In cases of primary lumbar curva- 
ture, or when the secondary curve of this region is pronounced, 
the attitude may be improved and the deformity may be cor- 
rected in part by seating the patient on an inclined plane, the 
high side beneath the low hip, thus lessening the convexity of 
the curve. 

The High Shoe. The same object may be attained in the 
erect posture by the use of a higher heel, or heel and sole. The 
elevation may be from a half-inch to an inch and a quarter, the 
amount being regulated by its effect upon the contour of the 
trunk. 

Posture and Support during Recumbency. The atti- 
tudes habitually assumed during recumbency should be investi- 
gated. The bed should be provided with a hard mattress and a 
low pillow, and the patient should be encouraged to lie habitually 
upon the side which opposes the deformity, or upon the back. 
The rectification induced by such an attitude may be still further 
increased by the use of a hard pillow beneath the convexity or 
beneath the back, and in certain instances the Barwell sling may 
be employed with advantage. 

General Treatment. The importance of improving the gen- 
eral condition of the patient by regulation of the diet, by cold 
baths, and by active exercise in the open air is self-evident. The 
strain upon the back should be lessened by providing proper 
seats and by limiting the time passed in passive attitudes, and by 
lessening, as far as possible, the restraint of the clothing. These 
precautions are of almost equal importance with the active treat- 
ment. 

The Duration of Treatment. The duration of treatment depends, 
of course, upon the character of the deformity and upon its causes. 
In the ordinary type of adolescent scoliosis the duration of active 
treatment is usually from three to six months. In this time the 
muscles may be so strengthened and the necessity for constant 
attention to the attitudes may be so impressed upon the patient 
that the simple exercises which may be performed at home may 

■ Zeit. f. Orthop. Cbir., 1902, Bd. x. B 2 



oi:rii<>r/:i>ic surukri. 



be Buffioient In such exercises the most important postures are 
those which hyperextend the spine. The constant effort should 
be to make motion in one direction as free as in another, and to 
practice postures that tend to reduce deformity. In all cases it 
is well, if possible, to keep the patient under supervision during 
the period of growth. 



CHAPTER IV. 

DEFORMITIES OF THE SPINE (Continued). DEFORMITIES OF 

THE CHEST. THE FUNCTIONAL PATHOGENESIS 

OF DEFORMITY. 

Variations in the Contour of the Spine. 

One recognizes a certain contour of the spine as normal, but 
there are variations from this type which, within certain limits, 
can hardly be classed as abnormal. Two of these have been 



Fig. 146. 



Fig. 147. 



7 



p> 





The hollow round back. (Hoffa. 



The round back. (Hofla.) 



mentioned: the raimd baek (Fig. 1 \~ ) in whirl, there is a gen- 
eral forward <\v<«> v most marked al the shoulders, and tin- hollow 



22 1 ORTHOPEDIC SURGERY. 

round back (Fig. L46) in which the dorsal kyphosis and the 
Lumbar lordosis arc somewhat exaggerated. A third type is the 
flat back ( Fig. 82) in which there is neither a lumbar lordosis nor 
a dorsal kyphosis. In the marked cases there is an actual promi- 
nence in the Lumbar region, while the scapulae project backward, 
overhanging the flattened dorsal spine. This type of back is the 
result, in many instances, of a rhachitic kyphosis which was most 
prominent in the lumbar region, and it often follows a primary 
lateral rotation of the lumbar vertebrae. The flat back and the 
round back predispose to lateral curvature. Deviations from 
the normal contour of the spine are attended by a change in the 
inclination of the pelvis and in the relation of the support of the 
limbs and trunk. The round back (Fig. 147) is almost always 
indicative of weakness, and it is often accompanied by other 
postural deformity, especially often by weak feet. 

Anteroposterior Deformities of the Spine. 

Kyphosis. As has been stated in the chapter on Pott's dis- 
ease, the spine is practically straight at birth. If during the 
early weeks of life an infant be placed in the sitting posture the 
head falls forward and the spine bends into a long posterior curve, 
the posture of weakness. The normal anterior convexity of the 
cervical section is established when the gain in muscular power 
enables the infant to hold the head erect, and that of the lumbar 
region when the pelvis is tilted downward by the extension of 
the thighs in the erect posture. 

In the erect posture the constant tendency of the weight of the 
head and of the thoracic and abdominal organs is to draw the 
spine forward and to re-establish the original posterior curve. 
This tendency is resisted by the action of the posterior muscles 
of the trunk. Whenever, therefore, the muscular power is 
Lessened or the body is overburdened, or whenever the spine is 
weakened by disease, the tendency toward the original curve of 
weakness becomes apparent (Fig. 148). Thus, the causes of an 
abnormal increase in the posterior curvature of the spine are very 
numerous. It is, as has been stated, the characteristic attitude 
<»f weakness, :i- is illustrated in infancy and in old age. It is 
one of the common occupation deformities of adult life; it is a 
common postural deformity of childhood and adolescence. It 
may be induced by a variety of diseases that lessen the resistance 
of the -pine or that interfere with its function. For example, 



DEFORMITIES OF THE SPINE. 



225 



by rhachitis, spondylitis deformans, osteitis deformans, Pott's 
disease, and affections of a similar nature. 

The kyphosis of rhachitis is most marked in the lower region, 
that of spondylitis deformans may involve the entire spine, while 
the simple postural curvature is most marked in the upper dorsal 
region — " round shoulders.'' In a number of the postural 
deformities the increase in the dorsal kyphosis is balanced by an 
increased lordosis, and in this form there is simply an exaggera- 

FlG. 148. 




Marked posterior curvature of the spine apparently induced by weakness incidental 

to illness. 



tion of the normal curves of the spine— the " hollow round " 
back. In other instances there is a general forward droop of 
the trunk in which the lumbar lordosis may be lessened ; tin- 
form is more common in childhood — the " round " back. 

The forms of kyphosis that arc the dired result of dig 
have been described elsewhere. Postural kyphosis— "round 
shoulders"— is one of the common deformities, and in childhood 

15 



22(i 



ORTHOPEDIC srilOERY. 



iimilar to that of lateral curvature, of which it 
may be a predisposing cause. Round shoulders and the accom- 
panying Hat chest may he induced also by obstructions in the 
respiratory passages, such as enlarged tonsils, adenoids, and the 
like, or by bronchitis or heart disease. Another predisposing 
cause is clothing that prevents the full expansion of the chest 
and the extension of the anus, and even the weight of clothing 
suspended from the shoulders may be a factor in the etiology. 



Fig. 149. 



Fig. 150. 




sea for the correction of posterior curvatures of the spine. (Hoft'a.) 



These and other possible contributing causes should be investi- 
gated in all cases of this type. 

A marked type <>f deformity is sometimes seen in adolescents 
(Fig. 7"),, Induced apparently by posture and by overwork, 
although in mosl instances it maybe assumed that a slighter 
deformity of long -t;in<linL r serves as a predisposing cause. In 
i hi- type the deformity is resistant, and there is, as a rule, pain 
nr discomfort mosl marked in the lumbar region. 



DEFOBJIITIES OF THE SPIXE. 



227 



Treatment. The treatment is similar to that of lateral curva- 
ture. The assumption of the military attitude with the head 
erect, the chin depressed, the shoulders thrown back, the chest 
expanded, and the abdomen retracted, should be encouraged. 
And those exercises that expand the chest aud that strengthen 
the muscles of the upper part of the spine are especially impor- 
tant. (Such exercies are illustrated by Figs. 97, 98, 105, 106, 
111, 112, 121, 127, 129, 131, 149, and 150.) If the range of 
vertical extension of the arms is limited, this restriction must be 
overcome before the deformity of the spine can be permanently 



Fig. 151. 




Tempered steel uprights for round shoulders. (Bradford and Lovett. I 

improved. In well-marked cases the patient should be encour- 
aged to read or study in the prone posture; in this attitude, in 
which the trunk must be supported upon the elbow- and the head 
held backward, there is necessarily an involuntary correction of the 
deformity. In certain instances a light spinal brace or corset may 
be employed during the hours when the passive attitude must be 
assumed (Fig. 151 ). Shoulder braces, so-called, are useless, because 
the lumbar lordosis is increased when the shoulders are drawn back- 
ward. Clothing should not restrict the movements <»f the arm- 
or trunk, and as little weight a- possible should !»<■ suspended 
from the shoulders. In the more extreme cases, in which the 



>2-2S ORTHOPEDIC SURGERY. 

kyphosis is of long duration and rigid, forcible correction after 
the Calol method is indicated as a preliminary treatment. Fixed 
support, preferably the plaster corset, is employed until the 
patient lias become accustomed to the new attitude. Afterward 
treatment by exercise and posture is continued as in the ordinary 
type. Whenever a patient is under treatment for deformity of 
the trunk the attempt should be made to restore the proper rela- 
tion of the body and limbs, and thus to restore the general 
symmetry of the body. 

Lordosis. Lordosis, or an abnormal hollowness of the back, 
is far less common than kyphosis. It is not a simple postural 
deformity, but it is usually secondary to disease or deformity 
either of the spine or of the adjoining members. For example, 
lordosis may be induced by flexion contraction of the thighs ; it 
is a symptom of congenital displacement of the hips; it is some- 
tine— a result of certain forms of nervous disease, in which, 
because of muscular weakness, the body is swayed backward to 
retain the balance, as in pseudohypertrophic paralysis. Lordosis 
in the lumbar region may be a compensation for a kyphosis in 
the upper segment. It is caused directly by spondylolisthesis. 
It may be a congenital deformity, and it is said to be a peculiarity 
of contortionists. 

Treatment. As lordosis is usually a secondary deformity its 
treatment would be included in the treatment of its causes. In 
some in-tances the discomfort which is usually present when the 
deformity i- well marked may be relieved by a proper corset 
sufficiently strong to support the back. 

Congenital Elevation of the Scapula. 

Synonym. Sprengel's deformity. 

Sprengel's deformity is a congenital elevation of the scapula 
above the level of its fellow, an elevation accompanied in most 
instances by rotation, so that its lower angle is brought nearer to 
the spine. Tlie cervical muscles passing to the scapula are short- 
ened and changed in direction. Thus, its mobility is lessened 
and consequently the range of vertical extension of the arm is 
restricted. In many in-tances the deformity is accompanied by 
a lateral curvature of the spine, the convexity being usually 
toward the deformed side. In a case treated at the Hospital for 
Ruptured and Crippled the elevation of the scapula was accom- 
panied by marked torticollis and asymmetry of the face, and in 



BEEOHMITIES OF THE SPIXE. 



229 



Fig. 152. 



2 cases reported by Wilson and Rngh' the posterior border 
of the scapula was attached by a bony process to the spine of 
the seventh cervical vertebra. In 4 cases — 3 reported by 
Kolliker 2 and 1 by Hoffa — the projecting upper border of the 
scapula, reaching nearly to the clavicle, was mistaken for an 
exostosis. 

The first adequate account of the deformity was that of Spren- 
gel, 3 who described 4 cases in children from one to seven years 
of age. In 1898 Pitsch 4 described 17 other cases collected from 
the literature, and two years later Roger' reported 32. Of these, 
30 were unilateral and 2 were bilateral. 

Etiology. The etiology is doubtful, but the deformity appears 
to be the result of a constrained position of the foetus in utero. 
In two of Sprengel's cases, seen soon 
after birth, the arm appeared to have 
been fixed behind the back of the child. 

It is of interest to note that, accord- 
ing to Chievitz, the upper limb is in its 
origin a cervical appendage retaining 
an elevated position during foetal life, 
and that interference with its descent 
by constraint or otherwise may explain 
the etiology. 

Congenital elevation of the scapula 
may be simulated by the distortion and 
muscular atrophy resulting from birth 
palsy, or even by certain cases of rotary 
lateral curvature in which the scapula 
is elevated and prominent. 

Treatment. If the case is seen in 
childhood and if the contraction of the 
vertebroscapula muscles is extreme, the 
shortened tissues may be divided by open 
incision as in torticollis, and if the 
scapula is joined to the spine, the bony process should be re- 
moved. In older subjects no treatment other than that for t In- 
lateral curvature is, as a rule, indicated. 




Congenital elevation ot (he lt'ft 
scapula. (Wilson and Rugh.) 



1 Annals of Surgery, April, 1900. 
> Archiv f. klin. r.'riir , 1891, Bd. xlii. 
« Zeit. f. Orth. Chir., Bd. vi. H. 1. 



'- Centralbl. f. Chll 
• Ibid., 1902, Bd. ix. 



230 ORTHOPEDIC SURGERY. 

The Absence of Vertebrae. 

Absence of vertebra is usually associated with rhachischisis. 
Several cases, however, have come under my observation in 
which there was absence of vertebrae without other malforma- 
tion. In two of the cases the deficiency was in the cervical 
region, in the others in the lumbar. The noticeable shortness 
of the affected section of the spine was the only symptom. 

Deformities of the Chest. 

The Flat Chest. The so-called flat chest is an accompani- 
ment of the round back (Fig. 147). In most instances the 
chest is not actually flattened in the sense that its anteroposte- 
rior diameter is diminished. It appears flatter because the shoul- 
ders and scapula? are displaced forward. 

Woods Hutchinson has called attention to the fact that the 
so-called flat chest is usually a round chest, in the sense that it is 
actually deeper than the normal, a persistence of the foetal type. 
He suggests that such persistence may be one of the causes of 
so-called round shoulders, the round chest affording no adequate 
mi p port for the scapula?. 

Hutchinson 1 has presented an index showing the relative depth 
of the chest at different ages, illustrating the progress from the 
keel chest of the lower orders to the bellows-shape of the adult 
human form. This index is found by dividing the anteroposterior 
diameter at the nipples by the transverse diameter at the same 
level ; hence the lower the index, the longer and flatter, more 
bellows-like the chest. 

Fretal index 103 

Infantile index ... 87 

Child •' 90 

Adult " 72 

Treatment. The treatment of the so-called flat chest is similar 
to that of the round shoulders with which it is often combined — 
thai is, by exercises conducted with the special object of improv- 
ing the strength of the muscles of the back and increasing the 
expansion of the upper part of the chest. The importance of 
correcting the deformity, which interferes with the proper expan- 
mmii of the Lungs and thus predisposes to disease, should be 
evident 

1 Journal American Medical Association, September 11, 1897. 



DEFORMITIES OF THE CHEST. 



231 



Pigeon Chest. Synonym. Pectus carinatum. 

The pigeon, or keel-shaped, chest resembles the quadrupedal 
type in that the anteroposterior is increased at the expense of the 
lateral diameter. The sternum is thrust forward and downward 
like the keel of a boat, the lateral compression being most marked 
at the junction of the ribs and the cartilages. This deformity is 
almost always acquired (Fig. 153); it is usually an effect of 



Fig. 153. 




General rhachitic distortions and pigeon chest. 



rhachitis, and it is described under that heading. It may be 
induced by obstruction of respiration caused by enlarged tonsils 
and the like, if this is present at an early age. It may be a 
secondary effect of the sinking forward and downward of the 
upper half of the trunk, as in Pott's disease of the middle of the 
spine. 

Treatment. The treatment of secondary deformity would be 
included in the treatment of the afiV-tion of which it is the result. 



132 



<>irniori:i)ic surgery. 



Manipulation, massage, and breathing exercises may he employed 
in the treatment of simple pigeon chest. The tendency is toward 
spontaneous cure ; it is rarely Been in adult life. 

The Funnel Chest. Synonym. Pectus excavatum. 

This deformity (Fig. 1 o4) is the reverse of the pigeon chest. 
The sternum is depressed and the lateral diameter of the thorax 
is correspondingly increased. The milder types of the affection 
in which there are one or more depressions or hollows in the 

Fig. 154. 




Pectus excavatum. Tins patient has ocular torticollis also. 



sternum arc common. The extreme form, in which the entire 
sternum is depressed, is rare. It is practically always a congenital 
deformity, and it is not susceptible to direct treatment. 

Minor Deformities of the Chest. As has been stated, distor- 
tion^ «.f the chest secondary to deformity of the spine are often 
discovered lnfore the original cause is suspected. And the impor- 
tance <>f the various minor irregularities of the chest or in the 



DEFORMITIES OF THE CHEST. 233 

direction of the ribs when once discovered is often exaggerated. 
They are usually the result of preceding rhachitis. The increase 
of the capacity of the chest by appropriate exercises aids in the 
correction of asymmetry. 

Absence of Ribs. Absence or defective formation of ribs is 
uncommon. In such cases there is usually defective formation of 
the corresponding muscles, and lateral curvature of the spine is 
a common accompaniment. 

Defective Formation of the Pectoral Muscles. Several 
instances in which one or both of the pectoral muscles were 
defective or absent have been observed at the Hospital for Rup- 
tured and Crippled. The malformation in these cases caused no 
direct symptoms. 1 

Absence or Defect of the Clavicle. A number of cases of 
defective formation of the clavicle on one or both sides are 
recorded. In most instances a portion of the sternal extremity 
is present. The defect appears to cause but slight inconvenience. 2 

Acquired Luxation or Subluxation of the Clavicle. 

Partial displacement of the sternal end of the clavicle is not 
particularly uncommon. In some instances it is caused by injury ; 
in others no cause can be assigned. Most often there appears to 
be a laxity of the capsular ligament that allows a displacement 
during certain movements of the arm. The displacement is 
readily reduced, but the weakness and insecurity may cause dis- 
comfort and disability. 

Treatment. In some instances the displacement may be pre- 
vented by the pressure of a pad and truss spring, attached behind 
to the corset or braces and passing over the shoulder close to the 
neck. Such an appliance is especially useful if the displacement 
occurs at certain times only, as in dressing the hair, playing on 
the violin, etc. Cures are reported as the result of the injection 
of alcohol into the joint from time to time, and Wolff 3 has 
operated with success as follows : The joint is opened by a 
straight incision. A fragment of bone is detached from the 
clavicle above and a similar one from the sternum ; these, still 
adherent to the periosteum, are overlapped in front of the joint 
and the capsule is then sutured. As a rule, the affection is not 
of particular importance. 

1 Martiren.'. Revue 'l'Orthoprdie, May. 1908. 
» Schornstein and Carpenter. Lancet, January 7, 1899. 
atralbl. f. Chir., November .30, 18'.»3. 



23 1 



ORTHOPEDIC SURGERY. 



Asymmetrical Development. 

In normal individuals there is often a slight difference between 
the two halves of the body, and, as is well known, inequality 
in the Length of the legs is not at all uncommon. Inequality of 
the two halves of the body may be congenital, and it may be 
evident at birth, but usually it does not attract attention until 
adolescence. In many instances this inequality is a slight 
atrophy, the result of a cerebral hemiplegia of early childhood. 

Fig. 155. 




Hypertrophy ot the right forearm and hand, due to congenital nsevus. 

In other instances the inequality maybe due to congenital hyper- 
trophy thai may affect the entire limb. In such cases the 
enlargement may be due to an abnormal amount of normal tissue, 
but in mosl instances the hypertrophy, which becomes more 
marked with the growth of the child, is caused by an abnormal 
blood supply, a form of congenital naevus (Fig. 155). 



THE FUXCTIOXAL PATHOGEXESIS OF DEFORMITY. 2^5 



Table of Weight, Height, and Circumference of the Chest in 
Childhood. (Boas.) 



-Rirth 'Male 

Birth (Female 

6 months. . . .{^f ale 

, v ___ /Male 

1 year \ Female 

18 months. . . . {& a £ ale 

2 YPflrs i Male 

^ years 1 Female 

o M (Male 

d ... -{Female 

4 >, ( Male 

( Female 

, „ (Male 

•-■••• (Female 
, „ (Male 

\ Female 

_ l( fMale 

\Female 

. .. (Male 

(Female 

o .. J Male 

1 Female 

10 ,. J Male 

} Female 

u tl fMale 

11 \ Female 

, 2 „ fMale 

"(Female 

„ ,. j Male 

) Female 

,« .. fMale 

I Female 

15 ., < Male 

(Female 



Pounds. Kilos. 



7.55 
7.16 
16.0 
15.5 
20.5 
19.8 
22.8 
22.0 
26.5 
25.5 
31.2 
30.0 
35.0 
34.0 
41.2 
39.8 
45.1 
43.8 
49.5 
48.0 
54.5 
52.9 
60.0 
57.5 
66.6 
64.1 
72.4 
70.3 
79.8 
81.4 
88.3 
91.2 
99.3 
100.3 
110. 08 
108.04 



3.43 
3.26 
7.26 
7.03 
9.29 
8.84 
10.35 
9.98 
12. 02 
11.56 
14.14 
13.60 
15.87 
15.41 
18.71 
18.06 
20.48 
19.87 
22. 44 
21.78 
24.70 
24.01 
26.58 
26.10 
30. 22 
29.07 
32.83 
31.87 
36.21 
36.90 
40.04 
41. 36 
45.03 
45.50 
50.26 
49.17 



Height. 


Ob 


Inches. 
20.6 


Cm. 


Inches. 
13.4 


52.5 


20.5 


52.2 


13.0 


25.4 


64.8 


16.5 ; 


25.0 


64.6 


16.1 


29.0 


73.8 


18.0 


28.7 


73.2 


17.4 


30.0 


76.3 


18.5 ' 


59.7 


75.6 


18.0 1 


32.5 


82.8 


19.0 


32.5 


82.8 


18.5 


35.0 


89.1 


20.1 


35.0 


89.1 


19.8 


38.0 


96.7 


20.7 


38.0 


96.7 


20.5 


41.7 


106.8 


21.5 


41.4 


105.3 


21.0 


44.1 


112.0 


23.2 


43.6 


110.9 


22.8 


46.2 


117.4 


23.7 


45.9 


116.7 


23.3 


48.2 


122.3 


24.4 


48.0 


122.1 


23.8 


50.1 


127.2 


25.1 ; 


49.6 


126.0 


24.5 ! 


52.2 


132.6 


25. 8 j 


51.8 


131.5 


24.7 ! 


54.0 


137.2 


26. 4 ' 


53.8 


136.6 


25.8 i 


55.8 


141.7 


27.0 


57.1 


145. 2 


26.8 


58.2 


147.7 


i7.7 


58.7 


149. 2 


28.0 


61.0 


155.1 


28.8 


60.3 


153.2 


29.2 


63.0 


159.9 


30.0 


61.4 


155. 9 


30.3 



Cm . 



34.2 
33.2 
42.0 
41.0 
45.9 
44.4 
47.1 
45. 9 
48.4 
47.0 
51.1 
50.5 
52.8 
52.2 
54. 8 
53.5 
59.1 
58.3 
60.6 
59.5 
62.2 
60.8 
63.9 
62.5 
65.6 
63.0 
67.2 
65.8 
68.8 
68.3 
70.6 
71.3 
73.3 
74.1 
76.6 
79 8 



The Functional Pathogenesis of Deformity. 

Wolff's Law. "Every change in the form and function of 
the bones or of their function alone is followed by certain definite 
changes in their internal architecture; and equally definite 
secondary alterations of their external conformation, in accordance 
with mathematical laws." 

Mention has been made, and will be made again from time to 
time, of the adaptation of members or parts to abnormal condi- 
tions, and of the transformation of deformed parts to the normal 
when the improper relations of weight and strain have been 
removed. This theory or law of functional adaptation has been 
established by Professor Julius Wolff, of Berlin, who has shown 
its application to the bones, the most unyielding structures of the 
body. He first called attention to the fact that the shape of a 
bone is the effect of function. It is the effect of function in thai 
if the work required of it had been different its shape would have 



236 



ORTHOPEDIC sriWERY. 



been different. This function has shaped not only the external 

contour but the internal structure as well. If a bone is broken, 

for example, the neck of the femur, and deformity results, the 

internal architecture is do longer suitable for the new conditions 

of weight and strain, and immediately a rearrangement begins, 

which final ly transforms the internal structure, not only in the 

neighborhood of the injury, but in the extremity of the bone also, 

to adapt the deformed part as well as may be to the work that is 

new demanded of it. 

Fig. 156. 




Dislocated femur, showing the atrophy and re-arrangement of the internal structure as 
compared with the normal (Fig. 157). (Freiberg.) 

The normal bone is braced most thoroughly, and is most 
resistant at the points where most work is required of it. If the 
weight and strain are for any reason transferred to another part, 
it- structure becomes bypertrophied there, and correspondingly 
weakened at the point from which the strain has been removed. 
With this change in the internal structure a change in the external 
contour keeps pace For, according to this theory, "the external 
contour represents mathematically simply the last curve uniting 



THE FUXCTIOXAL PATHOGEXESIS OF DEFORMITY. 237 



the ends of the various trajectories which make up the internal 
structure." 

For the further exposition of this theory I quote from Frei- 
berg's 1 review and abstract of Wolff 's 2 final article. 

" In showing that improper static demands made upon an 
extremity resulted in the formation of new masses of bone upon 
the surface of the bone of this extremity, or that they produced 



Fig. 15" 




Normal femur from same subject. (Freiberg.) 



the disappearance (atrophy) of bone masses according to the nature 
and degree of these disturbances in static requirements, it has at 
once been shown in what manner deformities have their origin. 
For these transformations on the surface of bones are nothing 
other than 'deformities' in the wider or narrower sense of the 
term. 

"Taking genu valgum or habitual scoliosis as example, the 

Annals of .Surgery, July, 1897 ; and American Journal of the Medical - 
1902. 

Lehre von der functionellen Pathogenic der DeformiUten, Archlv fur UinlSObfl 
Chirurgie, Bd. liii. II. I. 



238 



nirninr/:i)ic scrckiiy. 



development of a deformity in the narrow sense is thus explained. 
In the beginning of either of these conditions the shape of the 
bonee is perfectly normal. As the result of excessive fatigue in 
their too weak muscles the patients are frequently assuming a 
faulty position of limb or body; they seek to control excessive 
excursions of their joints by the interference of the articular 
structures themselves instead of by muscular activity. The 
result is a continual alteration in the static requirements made 
upon the bones and the internal architecture; internal and 
external configuration of the bones accommodate themselves to 
the new conditions. Since, according to this reasoning, deform- 
ities are nothing less than the result of these transformations 
which the external form of bones or joints undergo in accom- 



FlG. 158. 




Section ot femoral head ot a paralytic idiot, aged thirty-five years, showing the extreme 
atrophy caused by disuse. (R. T. Taylor.) 

modating it-elf to faulty demands made upon them, it must be 
Belf-evident that these deformities are to be considered patho- 
logical only in the sense that hypertrophy of the cardiac muscle 
in valvular insufficiency is pathological. That which is really 
pathological i- only the altered static requirements, the abnormal 
mechanical function. Far from being pathological the deformity 
i- the only suitable or even possible form by means of which 
bone <»r joint can withstand the altered forces bearing upon it; it 
i- nature'- wa\ of securing the greatest possible service and 
strength, under tie- new conditions, with the use of the least 
possible amount <>f material. 

••The pathogenesis of deformities is, therefore, functional. 



THE FUNCTIONAL PATHOGESESIS OF DEFOBMITY. 239 

Genu valgum, for instance, represents only the functional accom- 
modation of femur, tibia, and knee-joint to the improper static 
demands made by the outward deviation of the leg. Just so are 
the shapes of the bones in club-foot the expressions of similar 
functional accommodation to an inward rotation of the foot, or 
even, sometimes, an inward turning of the whole lower extremity. 
The faulty position of an extremity under these circumstances is 
to be regarded rather as a cause of the deformity than as an 
effect. This faulty position must always occupy a place inter- 
mediate between the remote causes of deformity (hereditary pre- 
disposition, habit, muscular weakness, external conditions causing 
pressure or narrowing space of growth), and the anatomical results 
which these various remote causes bring about. 

" AVhen the altered demands upon an extremity do not occur 
spontaneously, as in the above iustances, but, on the other hand, 
result from a primary disturbance in the shape of the bones, due 
to trauma or bone disease with consequent softening or destruc- 
tion of tissue, there is added to this a secondary change in the 
external configuration of the bones, and there is thus caused a 
' deformity in the broad sense of the word/ The difference 
between the two varieties of deformity, therefore, lies only in the 
addition of a second etiological factor (the trauma, etc.) to the 
deformity in the broad sense. Both varieties have it in common 
that the shape of the bones and joints of the deformed part repre- 
sents nothing else than the expression of a functional accommo- 
dation to the faulty static demands made upon it. 

" As a secoud example by means of which to explain the cor- 
rectness of the doctrine of functional pathogenesis the author has 
selected scoliosis. In the first chapter the author showed in 
detail that the altered conditions in the length and height of the 
transverse processes of scoliotic vertebrae as well as corresponding 
conditions in the ribs of the scoliotic thorax are so evident as not 
possibly to escape notice, and that they can be explained in no 
other way than as functional accommodation to the circumstances 
of space, changed and brought about by the continual, faulty, 
and cramped position of the thorax; this is as true of the convex 
as of the concave side of the vertebral column, to which the trans- 
verse processes and ribs in question belong. It must be manifest 
that changed relations of one part of the skeleton to any other 
part of the skeleton (as far as space conditions are concerned) 
necessarily bring about changes in the mechanical demands made 
upon this part, and, therefore, changes in the directions and values 



2 K» ORTHOPEDIC SUROER V. 

of the pressure, tension, and shearing strains of each and every 
point in this part of the skeleton. The conclusion thus drawn, 
that accommodation to space means the same as accommodation 
to function, is of greatest importance to the general doctrine of 
functional accommodation. 

u The origin of the wedge-shape of the scoliotic vertebra now 
conies under discussion. It is assumed by the majority of writers 
that an abnormal softness of the bones is present in scoliosis by 
means of which a faulty position can model the bodies of the 
vertebra as it docs in the case of rhachitic disease of the bone, or 
as is really the case with the intervertebral disks in cases of 
' habitual scoliosis.' While unsupported by any pathologico- 
anatomical investigations, it is allowed possible, or even probable, 
that such softness of the bones plays a role in many cases of 
scoliosis. It is certain, however, that this is by no means always 
the case; as evidenced by the development of scoliosis after 
empyema in adults, and the great exaggeration in adult life of 
very -light scolioses originating during youth. It is concluded, 
on the contrary, that the vertebra may acquire its scoliotic wedge- 
shape entirely independent of the pressure of the superincumbent 
weight. Furthermore, in the absence of any abnormal softness 
of the bones, the body of a vertebra may lose height on the con- 
cave Bide and gain the same on the convex side through the 
1 tropic stimulus of function ' purely ; being simply an accommo- 
dation to the diminished space on the concave side and increased 
room at the convexity and the change of mechanical conditions 
consequent thereupon. 

u This simple and natural conception of the circumstances con- 
cerning the scoliotic wedge must obtain credence, especially since 
the old view, corresponding to the 'pressure theory/ has been 
long ago disproved by Hoffa and ^Xicoladoni — namely, that the 
concave Bide of the wedge is the seat of atrophy, and that this 
atrophy accounts for the loss in height of the vertebral body on 
this Bide." 

The importance of Wolff's theory, which shows how deformity 
may be acquired and how it may be avoided, is very evident. 
It is of equal importance in indicating the principles of treatment. 
For example, from the anatomical description of a club foot the 
distortion might appear to be irremediable, but on this theory 
one feels assured that if the foot can be fixed for a sufficient time 
in the overcorrected position, the influence of the new static con- 
ditions will immediately induce a transformation, not only in soft 



THE FUNCTIONAL PATHOGENESIS OF DEFORMITY. 241 

parts, but in the bones as well, that will finally effect a complete 
and absolute cure. So, also, the correction of a distorted bone 
by operative means is at best but imperfect ; if, however, the 
static conditions have been changed, nature will in time recon- 
struct the entire bone so perfectly that in a few years practically 
no trace of the former distortion, either in contour or internal 
structure, will be evident. Scoliosis might be cured as perfectly 
as the club foot or the bow-leg, were it possible to restore as 
easily the normal conditions of weight and strain. 



Atrophy of Bone. 

The writings of Wolff have called especial attention to the fact 
that bone is a living tissue very readily affected by changing con- 
ditions, and that atrophy or hypertrophy of bone may be local or 
general, according to the change in functional use of the affected 
part. 

Since the Roentgen ray has come into general use particular 
attention has been called to the atrophy of the internal structure 
of bone that follows lessened use or disuse, or from what is called 
trophic disturbance of nutrition from any cause. For example, 
after fracture or joint disease, or nervous affections, or even 
slight injuries of the nature of sprains, eccentric atrophy is 
apparent — that is, weakening of the lamellae of the spongy por- 
tion and decrease in thickness of the compact substance of the 
bone. 

This atrophy is not only rapid, but it may be widespread, as 
proved by the investigations of Sudeck, 1 who could distinguish 
atrophy of the bones of the foot within six weeks after fracture of 
the leg. Atrophy of bone is especially rapid as a result of acute 
affections of the joints, corresponding in this to the atrophy of 
the muscles under similar conditions. In the X-ray negative 
such atrophy is indicated by a loss of clearness of outline which 
18 replaced by a peculiar blur, resembling closely the infiltration 
due to disease. 

Weigel lias called attention to cases in which general trophic 
disturbance of an entire extremity was induced by injury of ;i 
joint. This disturbance was indicated by congestion, coldness and 
persistent weakness of the extremity, and it was always accom- 
panied by marked and general atrophy of the bones. Such atrophy 

1 Fortsc. auf dein Gebietf. ^er BOntgenftrahlen, Bd. iii. B 



242 ORTHOPEDIC SURGERY. 

may explain the delay in recovery after apparently slight injury 
or disease of a joint or other tissue. The treatment should be 
stimulative, and functional use of the weak part should be 
encouraged as soon as possible. 

After long-continued disuse the bones may be extremely fragile. 
This fact must be borne in mind when one attempts to correct 
deformity caused by paralysis, by rheumatoid arthritis, and the 
like. 



CHAPTER V. 

TUBERCULOUS DISEASE OF THE BONES AND JOINTS. 

Etiology. Three factors are recognized in the etiology of 
tuberculous disease : the infectious element (the tubercle bacillus), 
the general predisposition of the patient, and the local condition 
that favors the reception and the growth of the bacilli. 

Predisposition. The predisposition, both general and local, is 
spoken of as lessened vital resistance. A general predisposition 
to disease may be inherited or it may be acquired. Thus, a his- 
tory of tuberculosis in the immediate family of the patient is sup- 
posed to imply a lessened resistance to this form of disease. In 
a certain proportion, perhaps 25 per cent, of the cases, this in- 
herited predisposition is very direct and positive, but in the 
larger number the family history is as indefinite as in a similar 
class of patients under treatment for any other form of ailment. 
The acquired predisposition is of more direct importance since it 
would include the lowering of the vitality due to improper food 
and improper hygienic surroundings of every variety, together 
with the greater liability to depressing diseases and the more 
constant exposure to tuberculous infection that such conditions 
imply. Thus, tuberculous disease of the bones, as well as of 
other parts, is more common among the poor of cities than among 
the more favored classes. 

Mode of Infection. The tubercle bacilli may be introduced to 
the body by inhalation and find their way to the bronchial glands, 
or by the mouth and set up disease in the mesenteric glands, 
or, after infection of the nasal passages or neighboring parts, 
secondary disease of the cervical lymphatics may cause the 
so-called scrofulous glands of the neck. 

Latent Tuberculosis. It may be assumed that disease of the 
bronchial and mesenteric glands is not uncommon in individuals 
of apparently perfect health, since it is often discovered at 
autopsies in those who have died from other causes. This form 
of glandular disease is called latent tuberculosis, and it usually 
precedes a local outbreak in the bone or elsewhere. In many 
instances the disease may remain latent and finally disappear, or 
it may persist, and from time to time free bacilli or bit- of in- 




2 1 1 ORTHOPEDIC SURGER Y. 

footed tissue may escape into the blood current; by it they are 
deposited iu other parts, where, under favoring conditions, local 
disease may be set up. Depression of the vitality from any cause 
may be supposed to favor the progress of the glandular disease, 
which may lead to a dissemination of the infectious elements, and 
at the same time it may lessen the resistance of other tissues that 
may be exposed to the infection. This accounts for the well- 
known influence of certain diseases, such as measles and whooping- 
cough, not only in predisposing to local tuberculous disease, but 
in favoring its progress when it is already established. It is 
possible, also, that the bacilli that have found their way into the 
blood current more directly, as, for example, through wound 
infection, may set up primary disease of a bone or joint. In fact, 
it is stated by Koenig 1 that in fourteen of sixty- seven autopsies 
on subjects who had suffered from tuberculous disease of the 
bones and joints, no other foci were found in the body. In other 
instances the source of infection may be pre-existent disease of 
the lungs or of other internal organs. 

In 769 autopsies on children under twelve years of age, at the 
Hospital for Children, Great Ormond Street, London, reported 
by G. F. Still, 2 269 presented tuberculous lesions. Of these, 117 
were less than two years of age. 

The apparent channels of infection, as evidenced by the appear- 
ance of the glandular lesions, were as follows : 

Respiratorj- : 

Lungs 105 

Probably lungs 33 

Ear 9 

Probably ear 6 

153 = 57 per cent. 
Alimentary : 

Intestines 53 

Probably intestines 10 

63 = 23.4 per cent. 
Other cases : 

Bones or joints 5 

Fauces 2 

Uncertain 46 

53 

Northrup and Bovaird 8 have made similar observations at the 
NYw York Foundling Hospital : 

Infection by respiratory tract 148 

Infection by mesenteric lymph nodes .... 3 
Indeterminate 48 

200 

i Deutsche Chir., 1900, L. 28a, S. 157. = British Medical Journal, August 19, 1899. 

» Northrup. New York Medical Journal, February 21, 1891. Bovaird, ibid., July 1, 1899. 



TUBERCULOUS DISEASE OF THE BOXES AND JOISTS. 245 

In sixteen instances the process was confined to the bronchial 
glands, and in no instance were these glands found to be free from 
disease. 

Bovaird 1 has collected the reported autopsies on tuberculous 

children with reference to primary intestinal infection, and has 

called attention to the fact that the English observations are not 

in accord with others : 

Autopsies. Prim ^J;^ stinal 

German 236 9 = 4 per cent. 

French 128 

English 748 136 = 18 

American 369 5 = 1" 

1481 150 

Haushalter, 2 in 78 autopsies upon childreu dying from acute 
miliary tuberculosis, found in all but 4 disease of the tracheo- 
bronchial glands. In 44 this disease was the most ancient focus 
in the body. 

Local Predisposition. The local conditions that favor the 
growth of the tubercle bacilli may be induced by injury. Slight 
injury sufficient to cause, for example, a hemorrhage into the 
substance of the cancellous tissue induces a local congestion dur- 
ing the process of repair that provides the proper soil for the 
growth of the bacilli when they are deposited in its neighborhood. 
This has been proved experimentally by Krause, and it is sup- 
ported by clinical evidence. The great preponderance of disease 
in the lower over that of the upper extremities in childhood is 
supposed to be another argument in favor of the influence of 
injury in the causation of disease. 

In 513 of 3398 cases of tuberculosis of the bones and joints 
reported by Hildebrand, 3 Koenig, Mikulicz, and Bruns injury 
seemed to be a direct predisposing cause of the local disease (1 6.5 
per cent.). A much higher percentage than this has been 
assigned by certain writers, but the exact relation of traumatism 
to disease can only be conjectured. 

The primary disease is almost always in the newly-formed 
bone about an epiphyseal cartilage. This tissue is vulnerable ; 
it is, therefore, more exposed to direct injury ; it is subjected, 
also, to the strain of motion at the neighboring joint, and as the 
circulation is here more active the bacilli are more often 
deposited in this situation. 

1 Archives of Pediatrics, December, 1901, 
- Archly, de Med. des Enfant*, March, 1902. 
'- Deutsche Chir., 1902, L. 13. - 



246 ORTHOPEDIC SURGER Y. 

The vulnerability of growing bone accounts also for the relative 
frequency of bone disease in childhood, as compared with adult 
life. Injury not only causes a local predisposition to disease, but 
it favors its progress when it is once established. 

Distribution of the Disease. In 13,308 cases of tuberculous 
disease of the bones and joints treated at the Hospital for Rup- 
tured and Crippled the distribution was, in order of frequency, as 
follows : 

Vertebrae 5,662 = 42.5 per cent. 

Hip-joint 4,048 = 30.5 

Other joints 3,598 = 27.0 

13,308 

In a total of 3561 cases treated at the Hospital for Ruptured 
and Crippled and at the Yanderbilt Clinic during a period of 
five years, the distribution was as follows : 

Vertebrae 1432 = 40.2 percent. 

Hip-joint 1123 = 31.5 " 

Knee-joint 699 = 19.6 " 

Ankle-joint 196 = 5.5 

Elbow-joint 62 a 

Shoulder-joint 42 1= 3.1 

Wrist-joint 7> 

3561 

Trunk 1432 = 40.2 per cent. 

Lower extremities 2018 = 56.6 " 

Upper " Ill = 3.1 " 

The correspondence between these two tables of statistics is 
striking, and the number of cases is so large that the proportions 
may be accepted as approximately correct as applied to the dis- 
tribution of the disease in childhood. 

At the Boston Children's Hospital in a period of twenty-five 
years, 1869-1893, 3820 cases were treated. 1 The distribution 
was as follows : 

Vertebrae 1964 = 51.4 per cent. 

Hip 1402 = 36.7 

Ankle 300 = 7.8 " 

Knee 104 = 2.7 

Wrist ' . 20^ 

Shoulder 15 1 = 1.3 " 

Elbow 15 J 

3820 

Trunk 1964 = 51.4 per cent. 

Lower extremities 1806 = 47.2 " 

Upper " 50 = 1.3 

Side Affected. Disease of the joints is slightly more common 
on the right than on the left side of the body. At the Hospital 

1 Report of the Boston Children's Hospital. 



TUBERCULOUS DISEASE OF THE BOXES AND JOINTS. 247 

for Ruptured aud Crippled the proportions iu the cases treated 
during a recent period of ten years are as follows : 

Hip, right 53 percent. 

Knee, right 55 

Ankle, right 50 

Shoulder, right . 64 " 

Elbow, right 60 " 

It has been stated that one of the explanations of the great 
preponderance of the disease of the lower over the upper extremity 
is the greater liability to injury. The same explanation has been 
advanced to account for the greater frequency of disease on the 
right side, which is more marked in the upper than in the lower 
extremity, because the right arm is more liable to overwork as 
well as to injury. 

Sex. Tuberculous disease of the joints is somewhat more 
common among males than females. 

Of 3822 cases of Pott's disease treated at the Hospital for 
Euptured and Crippled, 2037, or 53 per cent., were in males. 

Of 3307 cases of disease of the hip-joint treated at the same 
institution, 1731, or 52.3 per cent., were in males. 

Of 1218 cases of disease of the knee-joint, combined statistics 
of Koenig and Gibney, 703, or 57.6 per cent., were in males. 

Age. In 5461 cases of tuberculous disease treated at the Hos- 
pital for Ruptured and Crippled, about seven-eighths of the 
patients were less than fourteen years of age. 

r vertebrae, 87.7 percent. 

Less than 14 years of age < hip, 88.2 

Mother joints, 71.7 " 

/-vertebrae, 7.7 percent. 
Between 14 and 21 years of age . . . .ship, 9.2 " 

I other joints, 10.7 " 

/-vertebrae, 4.5 per cent. 
More than 21 years of age -hip, 2.5 " 

Mother joints, 17.5' " 

Of 1259 cases of Pott's disease treated recently at the same 
institution, 1075, or 85 per cent, of the patients, were in the first 
decade ; 50 per cent, were three to five years of age, inclusive, at 
the inception of the disease. 

In 1000 cases of disease of the hip-joint the ages of the patients 
correspond closely to these; 87.2 per cent, were in the first 
decade, and 45.2 per cent, were from three to five year- of age, 
inclusive. 

In 1000 cases of disease of the knee-joint, 75 per cent, were in 

1 Knight. Ortbopedia. 



248 



ORTHOPEDIC SURGERY. 



the first decade and 40 per cent, were from three to five years, 
inclusive. 

In 339 cases of the ankle-joint, 70 per cent, were in the first 
decade and but 35 per cent, were included within the three years. 

The distribution of the disease and its relative frequency at the 
different ages is shown by Alfer's table of statistics from Tren- 
delenburg's clinic at Bonn. 1 







5-10 


10-15 15-20 20-25 25-30 


30-35 35-40 40-45 45-50 50-55 55-60 60-6565-70 


Total 


Vertebra 


59 32 


23 


9 


10 


3 


6 


3 


1 


4 








239 


Hip 


68 


59 43 


46 


9 


11 


6 





4 


1 


1 


3 


o 


j 241 


Knee 


47 


52 47 


37 


20 


11 


23 


11 


11 


3 


2 


8 


6 


3 


281 


Ankle 


5 


9 


10 


5 


2 


1 


1 


3 


2 





3 





2 





43 


Shoulder 





2 


2 


6 


3 





3 


1 


1 


2 


2 


1 








28 


Elbow 


7 


14 


14 


21 


12 


9 


6 


5 


9 


8 


5 


2 


2 





114 


Wrist 


1 








1 


5 








3 


1 


3 


2 


1 


3 





20 


Total 


207 


1 | 
195 14S 139 


60 


47 


42 


29 


31 


18 


19 


15 


13 


3 


966 



This table illustrates the well-known fact that disease of the 
upper extremity, relatively infrequent at all ages, is proportion- 
ately far more common in adult life than is disease of the lower 
extremity. Of the joints of the lower extremity, the knee and 
the ankle are proportionately more often diseased in later life 
than is the hip. 

Pathology. When the bacilli are deposited in a part, the irri- 
tation of their toxins causes a proliferation of the fixed cells 
which lie in direct contact with the germs, and about these a ring 
of leucocytes forms. The bacilli, the epithelioid cells including 
often one or more giant cells, together with the surrounding leu- 
cocytes, constitute the visible tubercle of bone, a minute grayish 
speck in the cancellous structure. The central cells about the 
bacilli, increasing in number, deprived of nourishment and 
poisoned by the toxins, die and are disintegrated to granular 
material, " caseate," and the tubercle changes to a yellow color ; 
but the bacilli, multiplying and escaping, form new tubercles 
about the original focus, which coalesce as the area of the disease 
enlarges. Meanwhile the surrounding tissue becomes congested, 
as the result of the irritation, and the fixed cells become organized, 
or partly organized, into a feeble, ill-nourished form of granula- 
tion tissue, representing the effort of the part to shut out and to 
expel the foreign substances formed by the disease. Or, if this 
local resi stance is effective, the cells become actually organized 
into firm granulations which surround and destroy the germs, and 

1 Beit, zur klin. Chir., 1891, Bd. viii. H. 2. 









TUBERCULOUS DISEASE OF THE BOXES AXD JOINTS. 249 

then are further transformed into scar tissue. But in most 
instances, either because the irritation is insufficient or because of 
the deficient vitality of the part, the granulations are feeble and 
unstable, and they in turn becoming infected by the multiplying 
bacilli serve onlv to extend the area of the disease. This granu- 
lation tissue, before and after the stage of infection, absorbs and 
destroys the bone. If the progress of the disease is slow, the 
cancellous structure is completely absorbed or is represented only 
by bone sand, but if the disease infiltrates the bone more rapidly 
it may destroy its vitality while its structure is still retained, and 
a sequestrum is formed. Such sequestra, consisting of rounded, 
yellow, crumbling masses of cancellous structure, from the size of 
a peanut to a hazelnut, are especially common in epiphyseal disease 
of childhood. In rare instances wedge-shaped sequestra are 
found with the base at the periphery of the epiphysis. These 
are supposed to be caused by the lodging of an infected embolus 
in a terminal vessel, thus cutting off the blood supply. 

By the formation of new tubercles at the periphery, and by 
the caseation of material in the centre of the diseased area, a 
cavity in the bone is formed, containing the debris of the granu- 
lation tissue and often sequestra of larger or smaller size, and a 
variable amount of fluid, made up of serum and leucocytes, that 
has exuded from the surrounding granulations. The walls of 
this cavity are formed by the tissue in which the disease is active ; 
the inner layer containing the tubercles in the various stages of 
formation and decay, the outer, composed of feeble, ill-nourished, 
granulation tissue as yet not infected, and beyond this the softened 
and infiltrated bone. If the disease has ceased to progress in 
any direction, the granulations contain more bloodvessels, they 
are of firmer consistency and more perfectly organized, and the 
-ub-tance of the bone is harder, showing the evidence of repair. 

One termination of epiphyseal disease is by enclosure of the 
focus by resistant granulations, behind which the bone solidifies 
and shuts in the disease, or, in favorable cases in which its area 
is small, completely absorbing and replacing it by Bear tissue. 

Extra -articular Disease. As a rule, the tendency of the pro 
is to expand and to force an opening through tli<- cortes of the 
bone to the exterior. In certain case- tlii- opening may form 
<.ut-ide the capsule of the joint, and through it tlx- products of 
the disease may be discharged into the overlying tissue-, forming 
a tuberculous abscess. Here, the same process of infection and 
extension of the area of disease continues, bul more rapidly than 



25< I ORTHOPEDIC SURGER Y. 

when it was confined within the bone. The surfaces of the muscles 
and fascia are infected, and are covered with an abscess mem- 
brane of violet or grayish-yellow color, made up of tubercular 
tissue and masses of fibrin, lying upon and loosely attached to 
the outer inflammatory or healthy granulations. 

The cavity of the abscess is distended with tuberculous pus 
usually of a thin consistency, composed of serous exudation, 
leucocytes, fibrin, masses of degenerated tissue and fragments of 
bone or bone sand. It is commonly of a whitish color, occasion- 
ally reddish from mixture with blood, and, in the later stages, 
yellow and serous- like. The abscess enlarges in the direction of 
least resistance, and in most instances finally perforates the skin 
by one or more openings through which its contents are dis- 
charged. Or, its boundaries may cease to extend, its contents 
may be absorbed, adhesions may form between its walls, and a 
spontaneous cure is effected. Extra-articular disease, without ulti- 
.mate involvement of the joint, is unusual. It is more common at 
those joints like the knee, elbow, and ankle, in which the bones 
are superficial ; it is very uncommon at the hip-joint, and it is 
practically impossible in disease of the spine. 

Perforation of the Joint. Usually the tuberculous process within 
the epiphysis, enlarging its area, comes into contact w T ith cartilage, 
and, perforating this, finds its way into the joint. While the 
disease is still confined within the bone, the tissues within the 
joint are involved in a sympathetic irritation or inflammation. 
The synovial membrane becomes congested and hypertrophied ; 
the synovial fluid is increased and changed in quality ; fibrin 
forms and is deposited upon the cartilage and upon the lining 
membrane of the capsule. It is stated by Koenig that the 
organization of these fibrinous deposits upon the cartilage plays 
an important part in its destruction, even when actual tuberculous 
disease is absent. As a result of the sympathetic inflammation 
within the joint, adhesions may form which may limit the area 
of the tuberculous disease and retard its progress after perforation 
has taken place. This process is similar to the inflammatory 
changes in the pleura caused by the underlying tuberculous 
disease. 

When the disease comes in contact with the cartilage it clisin- 
tegrates ; the tuberculous granulations breaking through and 
spreading over its surface destroy it in piecemeal, or, advancing 
beneath it. separate it from the bone in large, necrotic fragments. 
The synovial membrane becomes thickened and infiltrated, 



TUBERCULOUS DISEASE OF THE BOXES AND JOINTS. 251 

numerous tubercles appear upon its surface, which undergo the 
secondary changes that have been described, and the joint 
becomes, practically speaking, an abscess cavity. The surfaces 
of the bones are disintegrated by the disease, and the destruction 
is hastened by the pressure and friction due to muscular spasm 
and to functional use. The thickened capsule, distended by the 
fluid and solid products of the disease, is usually perforated, and 
a secondary abscess, communicating with it, is formed in the stir- 
rounding tissues. As results of the disease, secondary changes 
appear in the neighboring parts. The irritation of the periosteum, 
if the disease is of a quiescent type, may induce the formation of 
irregular layers of bone or osteophytes about the joint. A new 
formation of connective tissue proceeding from the layer of granu- 
lations that surround the disease may extend to the muscles and 
tendon sheaths, binding them together, and causing limitation of 
motion. The newly-formed connective tissue may be very vas- 
cular and irregular in formation, and intermixed with it may be 
masses of gelatinous or myxomatous tissue. This, according to 
Krause, is due to the venous stasis and cedematous infiltration 
caused by the pressure of the capsular contents and extracapsular 
proliferation of granulation tissue. These changes in the appear- 
ance and in the consistency of the tissues about the joint are 
characteristic of the so-called white swelling. 

Other Forms of Tuberculous Disease of Joints. All of the 
German writers describe forms of primary synovial disease, its 
frequency varying from 16 to 35 per cent, of the cases. It is 
more common in adult life than in childhood, and at the knee 
than at other joints. But Nichols 1 states that he has examined 
120 tuberculous joints, and has found in every instance one or 
more foci in the bone that apparently preceded the disease in the 
joint. 

Whatever may have been its origin, from the clinical stand- 
point, one must recognize a form of disease in which the symp- 
toms differ from the ordinary osteal type. It begins as a 
chronic synovitis, although the tissues are more thickened and 
infiltrated than in simple synovitis, and the muscular atrophy is 
more marked. Reflex spasm and limitation of motion are slight, 
and the symptoms are rather discomfort and fatigue after exertion 
than actual pain. After many months or years, when it may be 
assumed the bones are involved, the characteristic symptoms of 

1 Transactions American Orthopedic Association, vol. xi. 



252 ORTHOPEDIC SURGER Y. 

tuberculous disease appear. In one form of synovial disease the 
amount of effused fluid is large, and it is clear and serous-like in 
character — hydrops tubereulosus j but usually it is cloudy, and it 
may be purulent in character. 

A.8 has been stated, Koenig lays stress upon the important part 
played by fibrin in the chauges that take place within a joint. 
Fibrin deposited from the effused fluid forms in successive layers 
upon the cartilage. Into this fibrin vessels grow from the 
hypertrophied and infected synovial membrane, destroying the 
cartilage together with the underlying bone. If the synovial 
disease is primary the bone is destroyed superficially, but if it is 
secondary to synovitis disease within the epiphysis it is usually 
more extensive. Synovial tuberculosis is essentially a chronic 
affection and is often mistaken for simple or so-called rheumatic 
synovitis. 

Arborescent Synovial Tuberculosis. In this form the interior of 
the joint is covered with villous proliferations of the synovial 
membrane. It is not a distinct disease, but is an irritative hyper- 
trophy that is present in syphilitic and rheumatic as well as in 
tuberculous joints. Its especial interest lies in the fact that the 
hypertrophied synovial growths may cause mechanical interfer- 
ence with the function of the joint. 

Fig. 159. 




Lipoma arborescens. (Painter and Erving.) 

Lipoma Arborescens. Arborescent villous proliferations are 
formed of adipose and fibrous tissue covered with a layer of round 
cells. The hypertrophied masses which project into the joint are 
often of large size, attached to the synovial membrane by a 
smaller pedicle. They are single or multiple, and vary in color 



TUBERCULOUS DISEASE OF THE BONES AND JOINTS. 253 

from yellow to deep red. They may be of a soft or firm consist- 
ency. In this form of disease, as in that described in the pre- 
ceding section, there is usually pain, limitation of motion ; often 
the swollen joint is irregular in outline ; the hypertrophied syno- 
vial prolongations are sometimes apparent on palpation. 1 The 
exact diagnosis is usually made only after an exploratory incision, 
and in such an event the removal of the larger prolongation 
would be indicated. The outcome depends, of course, upon the 
cause, the hypertrophy depending usually on an underlying tuber- 
culous, syphilitic, or so-called rheumatoid disease. In the in- 
stances in which the hypertrophied tissue is in itself the cause of 
the disability, cure may follow its removal. 

Rice Bodies. Rice bodies are numerous small, grayish-white 
bodies resembling cucumber seeds that are found in certain forms 
of synovial disease, and particularly in tuberculosis of tendon 
sheaths. They are formed of fragments detached from the pro- 
liferating synovial membrane and possibly of simple fibrin, which, 
under the influence of pressure and attrition in the movements of 
the joint or of the tendon, assume the characteristic shape and 
appearance. These bodies, within a tendon sheath or joint, cause 
a peculiar creaking, perceptible to the touch when the part is 
moved. 

Dry Caries. Caries Sicca. In this form of disease, which is 
apparently primarily synovial, there is but little formation of 
fluid, and there is but little tendency toward cheesy degeneration 
of the tuberculous products. The infected granulations destroy 
the bone without forming sequestra, and usually without sup- 
puration. This form more often occurs at the shoulder-joint, 
and it is characterized by marked limitation of motion, extreme 
atrophy of the surrounding parts, and sometimes by forward 
displacement of the partly destroyed head of the humerus that 
may be mistaken for a primary dislocation. 

Septic Infection. When a tuberculous abscess has opened spon- 
taneously, or when it has been incised, infection with pyogenic 
germs is common, aud it occasionally occurs before a communi- 
cation with the exterior has been established. After such infec- 
tion the surrounding tissues become infiltrated, reddened, and 
sensitive to pressure. The discharge is greatly increased in 
quantity and changed in quality. The loeal pain and discomfort 
are aggravated; if the joint is involved the destruction of the 

1 Painter and Erving. Boston Med. and Surg. Journal, Blarcb 19 



264 ORTHOPEDIC SURGER Y. 

bone goes Oil with increased rapidity, and the constitutional effects 
of pyogenic infection appear. If the area of the abscess is small 
and if the drainage is efficient, this accident is of slight impor- 
tance, and it may even exercise a beneficial effect in stimulating 
the circulation and dissolving the effused material about a joint. 
But if the abscess has burrowed widely into surrounding tissues 
and if it communicates with an important joint it is a dangerous 
complication ; in fact, the greatest direct danger of tuberculous 
joint disease. Persistent suppuration exhausts the patient, and 
by lessening the vital resistance it favors the local advance of the 
tuberculous disease and its general dissemination. It is in this 
class of cases that amyloid degeneration of the internal organs is 
common, induced not by tuberculous disease, but by the secondary 
infection and its consequences. 

Repair. Repair in tuberculous disease may be accomplished 
by the absorption, ejection, or enclosure of the disease. The 
process of repair usually accompanies the advance of the destruc- 
tive process, and examples of the three methods of cure may be 
found in a single joint. 

The curative agent is the granulation tissue which forms about 
the area of disease, and which, finally becoming sufficiently 
organized to resist the infection of the bacilli, solidifies into 
til >rous tissue. In those cases in which the disease is not absorbed 
or completely thrown off in the abscess formation, but is enclosed, it 
becomes quiescent. In such cases traumatism, when, for example, 
the surrounding adhesions are broken down in the attempt to 
rectify deformity or to overcome anchylosis, may cause local 
recurrence of the disease. 

Prognosis. The prognosis w T ill be considered more particularly 
in the sections on disease of special parts. The danger to life is 
direct and indirect, and this varies greatly with the part that is 
affected and with the age of the patient. 

In disease of the spine the direct danger to life is greater than 
in joint disease, because of its situation, since it may involve the 
spinal cord or extend to the important organs in the neighborhood. 
Abscess may in rare instances, merely by its size and situation, 
endanger life, and when infected it is far more dangerous because 
of the difficult} in providing efficient drainage. The influence of 
deformity and its effect in compressing the internal organs and thus 
Interfering with the vital functions is another more remote element 
of danger in disease in tlii- situation. 

The danger to life from disease of the joints is in proportion to their 



TUBERCULOUS DISEASE OF THE BOXES AXD JOINTS. 255 

importance. In rare instances it may extend from the epiphysis to 
the shaft of a bone and set up an extensive osteomyelitis ; or the 
patient may be weakened by the suffering caused by active disease, 
but, as has been stated, the most direct and constant danger is from 
prolonged suppuration that follows septic infection. Danger from 
this source is much greater at the hip-joint than at the ankle or 
elbow, for example, because of the greater difficulty in preventing 
the burrowing of pus when infection has occurred. 

The indirect danger of tuberculous disease is its dissemination to 
more important organs. But it by no means follows that the 
disease of the joint is the source of the general infection. For, as 
has been stated, it may be inferred that nearly every patient with 
joint disease has also disease of the lymphatic glands, and in a small 
proportion of the cases there may be active disease of other impor- 
tant organs as well. Tuberculosis of the lungs, for example, is 
often preseut in the adult before the local outbreak in the joint 
appears, and it is in great degree because of this liability to disease 
of the lungs that the prognosis of joint disease becomes progres- 
sively worse with the age of the patient. 

This point is illustrated by the statistics of Koenig and Brims 
on the final results of disease of the knee and hip-joints, to winch 
attention will be called again in the special sections. In Koenig's 
cases of disease of the knee-joint the influence of age upon the 
death-rate is illustrated by the following table : 

Less than 15 years of age 20 per cent. 

From 16 to 30 years 24 

" 30 to 40 " 44 

More than 40 " 60 

In Brims' statistics the death-rate was of patients in the firsl 
decade, 36 per cent. ; in the second decade, 44 per cent. ; older 
than this, 72 per cent. 

The cure of latent tuberculosis in the lymph nodes as well as 
of active disease of the lungs or bones depend- upon the vital 
resistance of the patient. This vital resistance is lessened by 
pain, by confinement and lack of exercise. It is directly impaired 
by the exhausting suppuration and by the poisoning of the toxins 
incidental to septic infection. Under these conditions the local 
disease advances and a general dissemination is more probable. 
Tlii- accounts for the fact that death from general tuberculous 
infection is much more common in this class than when suppura- 
tion has been slight or absent. This point is again illustrated 
by the statistics referred to. The death-rate in the cases of dis- 
ease at the knee without absc< -- - 25 per cent., with abscess 



256 ORTHOPEDIC SURGERY. 

4(3 per cent. Death-rate in cases of disease at the hip with 
abscess 52 per cent., without abscess 23 per cent. 

It is probable that tuberculosis may be disseminated by opera- 
tion upon tuberculous joints, although the evidence upon this 
point is vague and conflicting. Gibney, contrasting two equal 
periods of thirteen years of service at the Hospital for Ruptured 
and Crippled, in the first of which no operations were performed 
on tuberculous subjects, states that in his opinion the deaths from 
this source have been proportionately no greater during the period 
of active surgical intervention than before. And an investiga- 
tion of the causes of deaths among the patients treated at the 
New York Orthopedic Dispensary and Hospital during a period 
of twenty years showed that at least 25 per cent, of these were 
due to tuberculous meningitis. 1 During this period there had 
been, practically speaking, no operative intervention, yet the 
proportion of deaths from this cause is certainly as great as in 
any statistics that have been reported. It would appear, then, 
that the danger of dissemination is not sufficient to deter one 
from performing any operation that seems to be indicated by the 
character of the local disease or by the general condition of the 
patient. 

Diagnosis. Diagnosis is considered at length in the sections 
on diseases of the special joints. The tuberculin test, although of 
some importance from the negative standpoint, is of no par- 
ticular value as establishing a diagnosis of joint disease, for the 
reason that tuberculous disease of the lymph glands is so com- 
mon even among those whose joints are free from disease. For 
the same reason it is valueless as a test of cure. This is illus- 
trated by the investigations of Frazier and Biggs 2 of patients 
clinically cured of local tuberculosis, some by operative means. 
In 78 per cent, of these a positive reaction to tuberculin- was 
obtained. The X-ray is often of value in demonstrating the 
effects of disease, and in certain instances it may indicate its 
exact locality and extent. As a means of early diagnosis of 
joint disease in young subjects, however, it is of little importance 
as compared to the physical signs, because of the non-development 
of the bony structure of the epiphysis, which alone appears in 
the negative. 

Treatment. From what has been stated of the causes of dis- 
it follows that the general treatment should include, if possible, 

1 Personal communication from Dr. David Bovaird. 
University Medical Magazine, February, 1901. 



TUBERCULOUS DISEASE OF THE BONES AND JOINTS. 



lot 



a change in the hygienic conditions, relief from the danger of 
further infection, pure air, and proper food. These are as essen- 
tial in the treatment of tuberculosis of the bones as of other parts. 

The importance of the constitutional treatment of tuberculous 
disease, more particularly the proper environment in which the 
greater part of the day and even the night may be passed in 
the open air, can hardly be exaggerated. 

As far as the cure of local disease is concerned, no treatment 
can be as effective as the prompt and thorough removal of the 
focus of disease, while it is yet limited in extent, and before the 
joint has become involved. This is practicable, however, in but 
a small proportion of the cases in childhood, because it is usually 
impossible to locate the disease accurately and impossible to 
remove it without sacrificing much of the healthy bone upon 
which the future usefulness of the part depends. At one time 
early operation, even complete excision of the joint, was justified 
on the plea that the disease might thus be eradicated. But now 
that it is known that in nearly all cases otner tuberculous foci 
exist in the body, and as the functional results after these early 
operations are far inferior to those attained under conservative 
treatment, early excisions are limited to the adolescent or adult 
cases. For in this class growth has been attained and the 
economic conditions require that the period of disability should 
be as short as possible. In this class, also, early exploratory opera- 
tions are often indicated, sometimes for the purpose of establish- 
ing the diagnosis, and if the disease is of the synovial type 
the removal of projecting folds of hypertrophied tissue and the 
direct application of irritants, for example, of pure carbolic acid, 
may be of service. Brace treatment is conducted with the aim of 
relieving the part of function — that is to say, from strain and 
injury. Functional use of a diseased joint delays natural repair, 
since it causes pain and thus reduces the reparative force, while it 
stimulates the disease and increases its destructive action. The 
details of treatment will be described in the consideration of dis- 
ease of special joints. 

Treatment by Drugs. The administration of drugs occupies a 
very subordinate place in treatment, since it is not believed that 
any drug exercises a direct action upon the local disease iu the 
bone. 

Cod-liver oil, the hypophosphites, the various preparations of 
iron or other tonics may be given at certain times with benefit, 
but the continuous administration of medicine during the years 

17 



258 



ORTHOPEDIC SURGERY. 



that are required to complete a cure is, of course, out of the 
question. 

Local Applications. Iodoform. Iodoform is supposed to 
exercise a direct germicidal action and also to stimulate the 
formation of the granulations that cast off or absorb the tuber- 
culous products and then become transformed into fibrous tissue. 
At one time direct injection of the remedy into the bones was 
advocated, but this has now been abandoned, and its use is prac- 
tically limited to the treatment of tuberculous abscesses and 
certain forms of synovial tuberculosis. Iodoform is ordinarily 
employed in an emulsion with glycerin or oil, 10 c.c. of 10 per 
cent, mixture being injected at intervals of two or more weeks. 
Several deaths from iodoform poisoning have been reported, but 
injections of this quantity of the drug are apparently free from 
danger. 

Carbolic Acid. Carbolic acid in dilute solutions was at one 
time injected into tuberculous cavities, but its use has been gen- 
erally discontinued because of the danger of poisoning. Recently 
Phelps has advocated the use of pure carbolic acid in the treat- 
ment of tuberculous abscesses and sinuses. This is injected into 
the fistula? or into the abscess cavity, which has been opened, and 
is allowed to remain for about a minute, when it is neutralized 
by copious injections of alcohol, after which the part is thoroughly 
cleansed by salt solution. Carbolic acid doubtless acts as a 
caustic, destroying the infected granulations and stimulating the 
reparative processes. Other remedies of this class, for example, 
tincture of iodine, chloride of zinc, actual cautery and the like, 
are also used, and in certain cases with benefit. In the treatment 
of tuberculous ulcerations ichthyol, balsam of Peru, and iodoform 
are among the drugs employed. Balsam of Peru dissolved in 
castor oil of a strength of about 10 per cent., as suggested by 
Van Arsdale, is a very satisfactory application. 

X-ray Treatment. The X-ray as a local treatment appears 
to act as a stimulant of the reparative processes. It is of espe- 
cial value as an adjunct in the cases in which the tissues about 
the joint are infiltrated and traversed by discharging sinuses. The 
exposure of the diseased tissues to the direct rays of the sun is 
certainly a harmless treatment, and it should be applied if occa- 
sion offers. 



TUBERCULOUS DISEASE OF THE BOXES AND JOISTS. 259 



ACTIVE AND PASSIVE CONGESTION IN THE TREATMENT 
OF AFFECTIONS OF THE JOINTS. 

Bier's treatment of tuberculous joint disease was suggested by 
the observation of Rokitanski, that phthisis was uncommon in 
individuals suffering from disease of the heart when the mechan- 
ical obstruction was sufficient to cause venous congestion of the 
lungs. 

Passive or venous congestion of a joint is attained by con- 
stricting the limb with several circular turns of a rubber bandage 
above the affected joint sufficiently to interfere with the return of 
the venous blood, but not with the arterial supply. 

The congestion is localized by bandaging the limb firmly with 
flannel or other somewhat elastic material up to the lower margin 
of the joint. AVhen properly applied the joint becomes swollen 
and dark red in color. The local temperature is raised. This 
is what Bier calls hot congestion, as distinct from cedema (cold 
congestion) that would result if the rubber bandage were applied 
so tight as to constrict the arteries. Passive congestion should 
not cause or increase pain. If it has this effect it is improperly 
applied or is unsuitable for the case (Fig. 160). 

The action of the venous or passive congestion is, according 
to Bier, as follows : 

1. It increases the formation of fibrous tissue and induces 
hypertrophy of the bones. 

2. It has a bactericidal action in infectious joint disease, 
notably tuberculosis. 

3. It exercises an absorptive effect on the effused products of 
disease and on new formations that check joint motion. 

4. It relieves pain and lessens the activity of progressive joint 
disease. 

The most important indication for passive congestion is in the 
treatment of tuberculous disease. 

As applied for the purpose, when the patient has become 
accustomed to its use, it is continued during the day and discon- 
tinued at night, the limb being elevated to allow for the escape of 
the venous blood. If applied for disease of the wrist-joint it is 
unnecessary to bandage the fingers, as the finger-joints are usually 
stiff either from disuse or from adhesions about the tendons — a 
condition for which treatment by venous congestion is indicated. 

Passive congestion for tuberculous joint disease should 1"- sub- 



260 



ORTHOPEDIC SURGERY 



ordinate*! to protective treatment, although this is not the opinion 
of Bier, who favors motion rather than fixation of the diseased 
joint, [t may be continued indefinitely according to its effect. 
AjB a rule, pain is lessened by the treatment and muscular spasm 
decreases. This latter effect is in part, at least, explained by the 
constriction of the muscles of the thigh. 



Fig. 160. 



Fig. 161. 





The alcohol lamp and chimney. Used 
for active congestion. (Bier.) 

Abscess formation or ap- 
pearance at least is apparently 
favored by the congestion. 
This may be treated by aspira- 
tion or incision, and by the in- 
jection of the iodoform emul- 
sion if desirable. 

Passive congestion is em- 
ployed also for the treatment 
of chronic disability following 
injury, for chronic disease, 
such as rheumatoid arthritis or other affection attended by 
infiltration of the tissues. In this class of cases the local con- 
gestion should be reduced by active daily massage instead of by 
elevation of the limb. 



The application of passive congestion. A, 
the alternate point for the application of the 
bandage, in order to avoid atrophy from con- 
tinuous pressure. B, the rubber bandage. 
(Bier.) 



TUBERCULOUS DISEASE OF THE BOXES AND JOINTS. 261 

The treatment of acute infectious processes by passive conges- 
tion occupies a subordinate or experimental position. 

Active Congestion. Active congestion is induced by the local 
use of heat, ordinarily hot dry air. 

In its simplest form the apparatus consists of an alcohol lamp 
provided with a long metal chimney reaching to a box of wood 
or metal, into which the limb is inserted through openings at 
either end. The box has one or more small openings for the 
escape of air and moisture. The limb is usually wrapped in 
sheet wadding, and is particularly well protected from the parts 
of the box which may come in contact with the skin. The heat 
is then applied, usually to about 250° or 300° F., for from 
thirty minutes to an hour daily. The degree of heat is indicated 



Fig. 162. 




The application of the hot-air box for inducing active congestion. The box. C, the ther- 
mometer. A, a metal pipe projecting from the box, into which the chimney of the lamp is 
placed. B, lamp chimney. (After Bier.) 

by a projecting thermometer, and it is regulated by the comfort 
of the patient and by the observation of its effects. 

Bier prefers simple boxes of wood of various shapes suitable 
for the different parts of the body, lined with packing cloth 
soaked in a solution of water glass. He considers those as effica- 
cious as the complicated and expensive appliances, and at the 
command of all who desire to employ the treatment (Fig. 162). 

The effect of the heat is to induce arterial instead of venous 
hyperemia, and to cause profuse local and general perspiration. 
Active hyperemia is not suitable for the treatment of active or 
progressive joint disease. It exercise- a dissolving and absorb- 
ing action on effused material and on the tissues of new forma- 
tion causing limitation of motion within a joint. It increases 



262 



ORTHOPEDIC SURGERY. 




local nutrition and it relieves pain. It is especially indicated in 
the treatment of local disability after injury, chronic effusions 
into joints, rheumatoid arthritis, chronic rheumatism, and the 
like. 

As a rule, the application of local heat should be supplemented 
by massage. The profuse general perspiration that is induced 
by it is a contraindication in weak individuals. 



CHAPTER VI. 

NON-TUBERCULOUS DISEASES OF THE JOINTS. 
Syphilitic Diseases of the Joints. 

In early infancy the characteristic syphilitic disease of the 
bones is a form of osteochondritis. Painful, sensitive swellings 
appear at the epiphyseal junctions, either as small, hard tumors, 
or as general enlargements, resembling those of rhachitis (Fig. 
163). As a rule, several epiphyses are involved, more often 
those at the distal extremities of the bones of the lower limbs, 
and in these cases the pain and discomfort may induce an appear- 
ance of helplessness of the part called pseudoparalysis (Parrot). 
In osteochondritis there is a multiplication and irregularity of 
the cartilage cells of the ossifying layer and premature calcifica- 
tion. As a result, the circulation is insufficient and necrosis of 
a part of the cartilage may follow, which, acting as a foreign 
body, sets up inflammatory changes in the adjoining parts. The 
process is shown by a zone of hard, dry, yellow substance in the 
ossifying layer, adjoining which is an inflammation of the tissues 
of the newly formed bone which is in part replaced by granu- 
lation tissue. If the disease is progressive, ulceration and sup- 
puration may follow; the cartilage may be destroyed, and the 
epiphysis may be separated, causing deformity and cessation of 
growth. The neighboring joint is usually involved in the dis- 
ease. In the milder cases there is a simple sympathetic synovitis ; 
in the advanced class a destructive arthritis. In one case seen 
recently the symptoms of pain on motion combined with slight 
effusion into several joints were present without the epiphyseal 
enlargement. The affection may be distinguished from rhachitis 
by the accompanying evidences of inherited syphilis, by the 
irregularity of the epiphyseal involvements, and by the age of the 
patient and the absence of the other symptoms of rhachitis. 

In the laU /• manifestations of hereditary syphilis, in which the 
bones in the neighborhood of the joint arc involved in syphilitic 
osteoperiostitis, the joint may be sympathetically affected or the 
disease may actually perforate the joint. In this form of disease 



264 



ORTHOPEDIC SURGERY. 



the synovial membrane is usually hypertrophic^! and it may 
interfere with the function of the joint. The fluid is increased 
in quantity and the affection may resemble synovial tuberculosis. 
A slow, chronic, infiltrating gummatous form of disease appear- 
ing in later childhood may simulate very closely the appearances 
of so-called white swelling. It is more common at the knee, 
but other joints are often affected as well. 

Fig. 163. 




Suppurative syphilitic epiphysitis at lower ends of radius and tibia in an infant aged 
one month. The child died shortly after the drawings were made, and the epiphyses were 
found lying loose in purulent cavities. (Tubby.) 

In the secondary stage of acquired syphilis pain and swelling 
of the joints, resembling rheumatism, may be present, and in 
tertiary syphilis the joint may be involved in disease of the 
neighboring bones, or the joint itself may be primarily implicated. 

In most instances the joint affections of syphilis are explained 
by the history and by the other signs of syphilitic disease. Spina 
ventosa | Fig. 165), which is classed as one of the evidences of 
syphilis, is far more commonly of tuberculous origin, as is illus- 
trated by the statistics of Karewski, 1 of 157 cases, in which but 
three were due to syphilis. 

Syphilitic disease of the joints is uncommon in orthopedic 



Chlr. Krank. des Kindesalters. 



XOX-TUBEBCULOUS DISEASES OF THE JOIXTS. 



265 



clinics as compared with those of tuberculous origin. This is as 
might be expected, for not only is tuberculosis far more common 
than syphilis, but a very large proportion, according to Fournier, 
77 per cent., of the syphilitic children are stillborn or die 
shortly after birth. Even in those that survive, disease of the 
bones or joints in the form that could be confounded with tuber- 
culosis, is uncommon as compared with its other manifestations. 



Fig. 164. 




Syphilitic osteoperiostitis of the tibiae resembling anterior bow-leg. This is the most 
characteristic manifestation of hereditary syphilis. 

Treatment. Some writers consider hereditary syphilis to be a 
very important predisposing cause of tuberculous disease, and be- 
lieve that many cases classed as tuberculous are in reality syphilitic, 
even if no history or confirmatory signs of syphilis are present. 
There is no reliable evidence to support this view. The possibility 
of the syphilitic taint, remote or direct, should be borne in mind, 
and in doubtful cases appropriate remedies should be employed. 

In general, the treatment of the joint affection would be 



266 



ORTHOPEDIC SmoKRY. 



included in the appropriate treatment of the disease of which it 
is a complication. If the joint is involved in a destructive 
process appropriate apparatus to insure rest and protection is 
indicated. The removal of irritative disease in the neighborhood 



Fig. 165. 



Fig. 166. 





Hereditary syphilitic disease of the meta- 
carpus and phalanges. 



Hereditary syphilitic disease of the 
joints. In this case the interior of the 
right knee-joint was lined with hyper- 
trophied folds of synovial membrane. A 
complete cure followed the administration 
of appropriate remedies. 



of a joint is sometimes possible in older subjects, and in this class 
of cases an exploratory incision for inspection of the joint is some- 
times advisable (Fig. 166). 



XOX-TUBERCULOUS DISEASES OF THE JOIXTS. 267 



Gonorrhceal Arthritis. 

Synonym. Gonorrheal rheumatism. 

So-called gonorrhceal rheumatism is an inflammation of a joint 
caused by the presence of gonococci. It is said to complicate 
from 2 to 5 per cent, of all the cases of gonorrhoea, usually ap- 
pearing in the later stages of that affection, and it is more com- 
mon among those who are in a debilitated condition. 

Distribution. In about 40 per cent, of the cases it is mon- 
articular and the knee-joint is most often involved. In 375 
cases collected by Finger the distribution was as follows : x 

Knee 136 Shoulder 24 

Ankle 59 Hip 18 

Wrist 43 Jaw 14 

Finger-joints .... 35 Other articulations . . .21 



Elbow 25 



375 



Bennecke 2 has tabulated 78 cases recently under treatment. 
The 78 cases occurred in 56 patients, of whom 18 were males, 
38 females. The distribution was as follows : 



Knee 


. 31 


Shoulder 


. 4 


Hip 


. 8 


Elbow . 


. 10 


Ankle 


. 9 


Wrist . 


. 6 


Other joints of foot . 


. 6 


Fingers 


. 4 



78 



In 46 cases recorded by Markheim 3 one joint was involved in 
13 cases, two joints in 12, three joints or more in 18. The order 
of frequency was knee, hip, shoulder, wrist, and elbow. 

Symptoms. The affection is usually of a subacute character. 
The joint becomes swollen and there is discomfort, and particu- 
larly weakness, and stiffness on use. If the infection is more 
severe there may be local heat, pain, and infiltration of the 
tissues with accompanying muscular spasm. 

In all the forms the infiltration of the subsynovial tissues of 
the capsule and of the superficial tissues is more marked than the 
actual effusion within the joint. The more serious cases are char- 
acterized by a peculiar redematous, boggy swelling of the tissues, 
and the skin is hot, sensitive, and glazed. There is usually 
intense pain on motion of the limb or on jar. After the subsi- 
dence of the acute symptoms the thickening persists, and practical 
anchylosis may result. 

1 Taylor. Venereal Diseases, p. 203. 

■ Die Gon. Gelenkentziindung nach beob., rter Chir. Univ. Klin, in u*er K. CharitC- zu Ber- 
lin. HirschwaM, Berlin. 
3 Deutsche Arcbiv f. klin. Med., 1902, vol. lxxii. p. 



268 ORTHOPEDIC SURGER Y. 

Gonorrhoea! arthritis has been divided into three classes accord- 
ing to its symptoms and physical characteristics : the serous, the 
serofibrinous, the purulent. 

The serous form is, as its name implies, a simple effusion 
resembling other forms of subacute synovitis, although it is of a 
more chronic character. 

The serofibrinous variety is the so-called plastic type of inflam- 
mation. In this form fibrin is deposited upon the cartilage and 
it is afterward organized by the growth of vessels into it from the 
synovial membrane, a process which erodes the cartilage upon 
which the granulations rest. The folds of the synovial membrane 
adhere to one another, the capsule is thickened, and ligaments and 
tendons may be involved in the adhesive inflammation. These 
changes within and without the joint may seriously impair its 
function after the cure of the active disease. 

The purulent form is uncommon ; it is similar in its character- 
istics to suppurative arthritis from other causes. It is attended 
by great local heat, pain and swelling, and by constitutional 
disturbance. 

In orthopedic clinics gonorrheal arthritis is usually seen in 
its later stages when the acute symptoms have subsided. In 
these cases swelling and pain persist in many instances, and in 
the more severe class motion is limited or the limb may be fixed 
in an attitude of deformity. An obstinate, monarticular, painful 
swelling of a joint suggests gonorrhoea, and its presence or absence 
should always be determined, since the effective treatment of the 
primary cause is essential to the cure of the secondary affection 
of the joint. The same statement is true of painful, persistent 
affections of bursa? and tendon sheaths, and of obstinate forms of 
weak foot. 

Treatment. The treatment of the early stage of this form of 
arthritis is rest and compression, together with hot or cold applica- 
tion.-, as may seem to be indicated. Ichthyol ointment in a propor- 
tion of about 40 per cent, appears to relieve the pain and to stimu- 
late the absorption of the effusion. If the symptoms are acute and 
if there is constitutional disturbance, the joint should be aspirated, 
and if the examination shows the effusion to be seropurulent, it 
should be treated by incision and drainage. In the chronic 
form, also, when the capsule is distended by the serofibrinous 
effusion, incision and removal of the contents is indicated. 

In the latter stages of disease of the ordinary subacute type, 
the treatment Is directed to the absorption of the effused material 



NON-TUBERCULOUS DISEASES OF THE JOINTS. 269 

within and without the joint, and to the restoration of functional 
activity. The use of hot air, massage, the hot and cold douche, 
static electricity and the like are of service in stimulating the 
circulation. If the limb has become deformed, and if it is fixed 
by adhesions and by contractions, the distortion may be corrected 
and adhesions may be ruptured by forcible manipulation under 
anaesthesia. And it may be stated that in this class of cases 
restoration of function to a greater or less degree is often accom- 
plished by this means. 

If, however, the limb is fixed in the proper position it is well 
to postpone forcible measures until the effect of the massage and 
gentle passive movements have been observed. 

Functional use is the most effective restorative treatment after 
the acute symptoms have subsided. This is made possible by the 
employment of apparatus which limits motion to the degree the 
joint permits without causing discomfort. 

Puerperal Arthritis. This is so similar in its characteristics 
to gonorrhceal arthritis that a detailed description is unnecessary. 
It may be stated, however, that puerperal arthritis is usually of 
a more severe type than the preceding affection. 



Arthritis Complicating Infectious Diseases. 

The joints may be involved in the course of any infectious 
disease. A mild form of arthritis, often involving several joints, 
is common after diphtheria or scarlatina, and it is occasionally 
observed as a sequel of pneumonia. 1 This is usually of a more 
severe type than the preceding forms. 

Arthritis following typhoid fever is often of a severe and 
destructive type. Keen 2 has tabulated 84 cases. In 4:> per 
cent, of these the hip-joint was affected and in 40 per cent, 
spontaneous dislocation occurred. In a case treated recently 
at the Hospital for Ruptured and Crippled there had been a 
destructive arthritis of one hip-joint, spontaneous displacement of 
the femur on the other side, and secondary contractions at the 
knees and ankles, so that the patient was bedridden. 

Treatment. The treatment in all forms of arthritis compli- 
cating diseases of this class is to place the affected joint at rest, 
to apply heat or cold as may be indicated by the local condition, 

1 Herrick. American Journal of the Medical Sciences, July, VJQ'2. 
* Surgical Complications and Sequels to Typhoid Fever. 



270 OR TH OPE DIC SURGEB Y. 

and to prevent the secondary distortions that lead to fixed 
deformities. The presence of pus is, of course, an indication for 
immediate incision and efficient drainage; thus, in all doubtful 
cases the character of the effusion should be ascertained by 
aspiration. 

Spontaneous dislocation, which is comparatively common when 
the hip-joint is suddenly distended with fluid, is not likely to 
occur unless the limb is flexed and adducted. This attitude 
should be prevented by the use of traction or support. 

The after-treatment has been indicated already. 

Prognosis. It is evident that the immediate reaction to bac- 
terial infection and the final results will vary with the virulence 
of the infection, the natural resistance of the individual and of 
the part involved. According to Poynton and Paine 1 the bacteria 
reach the synovial membrane through the capillaries of the 
areolar tissue, beneath the endothelium, which if uninjured serves 
as a barrier to protect the joint cavity. If the joint is not 
actually involved the restriction to motion will depend upon 
thickening of the tissues of the joint and upon disuse of the 
muscles. In such cases the prognosis is good. If, however, the 
interior of the joint is invaded by a process that causes adhesions, 
and partial destruction of the cartilaginous surfaces, anchylosis is 
likely to follow. 

Marsh 2 divides infectious arthritis into four classes : 

1. Simple infiltration of the subsynovial tissues and slight 
synovitis. 

2. Effusion of fluid into the synovial sac — synovitis. 

3. Infiltration of the periarticular tissues — plastic inflammation. 

4. General destructive arthritis. In the first and second classes 
complete recovery may be anticipated. In the third class a vary- 
ing degree of functional disability is to be expected In the last 
it is inevitable. 



Acute Arthritis of Infancy. 

A form of acute suppurative arthritis primarily within the 
joint or more often secondary to disease of the neighboring 
epiphysis is not uncommon in infancy. 

Etiology. The disease is usually caused by staphylococci, 
occasionally by other forms of infection. In the early weeks of 

1 British Medical Journal, November 1, 1902. 
- Ibid., December, 1902. 



XOX-TUBEECULOUS DISEASES OF THE JOIXTS. 271 

life it may follow infection at the umbilicus or other surface 
lesion. It may be secondary to one of the exanthemata or to 
gonorrhoea, but in many instances the origin is not apparent. 
Falls or blows upon the part appear to be predisposing causes. 

Townsend 1 tabulated 73 cases of acute arthritis, 18 of which 
were personal observations. To these I am able to add 12 
others, making a total of 85 cases. In 64 of these the infection 
was monarticular; in 21 more than one joint was involved. The 
distribution was as follows : 

Hip-joint 45 = 53 per cent. 

Knee-joint 32 = 37 

Other joints . ■ 8 = 10 " 

The sex was specified in 61 cases : males, 38 ; females, 23. 
It is of interest to note that in all reported cases the males out- 
number the females. In 285 cases, including the above and 
others reported by Gonser, Demme, Liicke, Billroth, Schede, and 
Miiller, the proportion was nearly 3 to l. 2 

Symptoms. If the infection is severe there is immediate local 
heat, redness, swelling and oedema, great pain, and correspond- 
ing constitutional disturbance. But in many instances the local 
and general symptoms are less marked, the child is fretful, and 
the evident discomfort caused by motion at the affected joint is 
mistaken for result of injury or rheumatism. In this class of cases 
the patient is not, as a rule, seen until several weeks after the 
onset of the affection. The joint is then somewhat infiltrated 
and enlarged, motion is painful and restricted, and the general 
appearances are very similar to tuberculous disease. There are 
also, without doubt, even milder forms of synovial infection 
from which recovery is rapid and practically complete. These 
cases are usually classed as monarticular rheumatism. 

Treatment. The treatment of the suppurative form is, of 
course, free incision and efficient drainage. In all cases the joint 
must be fixed, preferably by a light wire splint, during the active 
stage of the disease. An apparatus is usually required to prevent 
deformity or to support the weak limb when the patient begins to 
walk. 

Prognosis. If the arthritis is a primary disease within the 
joint complete recovery may follow evacuation of the pus, but, 
as a rule, the neighboring epiphyseal junction is diseased, sup- 
puration is prolonged, and a part of the epiphysis is destroyed 

1 American Journal of the Medical Sciences, January, 1890. 

2 Gonser. Jahrbuch f. Kinderheilk., July, 19 



272 ORTHOPEDIC SURGERY. 

before the disease comes to an end; thus, subluxation or dis- 
placement with subsequent deformity and loss of growth are the 
usual results of this form of disease. At the hip-joint, for 
example, the laxity of the ligaments and the upward displacement 
of the femur that follow destruction of the head of the bone 
cause symptoms that in later life are often mistaken for those of 
congenital dislocation. 

In some of the cases there is, in addition to the arthritis, an 
osteomyelitis of the shafts of one or more of the bones. These 
cases are usually fatal, or, if the patient survives, there is usually 
necrosis of the affected bones and consequently extreme deformity. 

In the cases reported by Townsend the death-rate was, in the 
monarticular form, 18 per cent. ; in the multiple form, 73 per 
cent. 

In a total of 122 cases of all varieties tabulated by Hoffmann, 
the death-rate was 46 per cent. In 87 the affection was confined 
to one joint ; in the remainder from two to five joints were 
involved. 1 

Acute Tuberculous Arthritis. In early infancy forms of 
acute tuberculous disease, especially at the knee-joint, may simu- 
late closely infectious arthritis. The joint may become swollen, 
hot, and sensitive to pressure, and the onset may be sudden and 
accompanied by constitutional disturbance. Such cases are more 
often observed in the children of mothers suffering from advanced 
disease of the lumrs. 



Acute Osteomyelitis. 

Infectious osteomyelitis is most common in early life, and the 
extremities of the bones in the neighborhood of the epiphyseal 
cartilages are most often involved. The symptoms are local 
sensitiveness of the bone, pain, and constitutional disturbance. 
The neighboring joint is usually distended by a sympathetic 
synovitis, and the overlying tissues are usually infiltrated. The 
treatment consists in immediate opening of the bone at the sus- 
picious point, in order to relieve the tension and to establish 
drainage. In certain instances the joint itself may be directly 
involved in the disease. This may be inferred if the symptoms 
do not subside after the bone has been opened. In doubtful 
cases tie- joint should be aspirated for the purpose of bacteriolog- 

Medical Bulletin, Washington University, September, 1902. 



XOX-TUBEECULOUS DISEASES OF THE JOIXTS. 273 

ical examination, but even if pathogenic bacteria are found the 
treatment by incision or otherwise must be decided on the clinical 

symptoms. 

Fig. 167. 




Deformities resulting from infectious osteomyelitis. 

Subacute Osteomyelitis. 

In older subjects localized infectious osteomyelitis in the neigh- 
borhood of a joint may simulate tuberculous disease. The onset of 
the affection is, however, more abrupt, the surrounding tissues are 
infiltrated, and the symptoms are usually more acute than in the 
latter affection. In this class of cases, of the subacute type, the 
lesions are often multiple, and in many instances the source of 
the original infection is evident. The treatment of choice is the 

18 



274 



ORTHOPEDIC SURGERY. 



operative removal of the diseased area, which is indicated by 
local sensitiveness, and which in many instances may be demon- 
strated by the X-ray. 



Fig. 168. 



3 •* V ^K I 

■-.:''■ m '.* 

Kfi ■ Ji 

, ■'■!*.• -iM i 




1 



Loss of growth following osteomyelitis of the tibia, necessitating removal of part of the shaft. 



Osteoarthritis and Rheumatoid Arthritis. 
Deformans. Rheumatic Gout. 



Arthritis 



Under these titles are included a group of chronic diseases of 
the joints whose etiology is obscure. At the present time these 
diseases are usually classed as varying manifestations of one 
pathological process, and the titles are usually considered as 
synonymous. 

Clinically, however, the characteristic types differ markedly 
from one another. In one form bone destruction is combined 
with bone formation, and the final result is an irregular solid 
enlargement of the joint, usually combined with distortion of the 
limb. 

It has been suggested by Goldthwait that the term osteo- 
arthritis should be applied to this type. 



NON-TUBERCULOUS DISEASES OF THE JOINTS. 275 

The second form resembles somewhat rheumatism in its course 
and distribution. The disease is primarily of the soft parts of 
the joint, the bone is only secondarily and superficially involved, 
and the final result is limited motion or anchylosis without 
enlargement of the joint. This form is sometimes classed as 
atrophic to distinguish it from the former or hypertrophic variety 

Fig. 169. 




Osteoarthritis. The hypertrophy of the extremities of the bones of the terminal phalanges 
(Heberden's nodes) is accompanied by erosion of the cartilage. The second interphalangeal 
joint of the second finger shows hypertrophy, combined with destruction and lateral dis- 
placement. (See Fig. 170.) 

of arthritis deformans, but the term rheumatoid arthritis seems 
to be preferable, as indicating that the two varieties of chronic 
joint disease are distinct. 

Pathology of Osteoarthritis. The disease appears to begin in 
the cartilage, which becomes fibrillated and destroyed in the parts 
subject''! to greatest pressure, while it is thickened and heaped up 



276 OR THOPEDIC S UR GER Y. 

into irregular layers at the periphery, as if under the influence of 
pre— ure it had been squeezed out from the interior of the joint 
( Fig. 171). The process is supposed to consist in a multiplication 
of the cartilage cells which in the free portion of the cartilage 
escape into the joint, while in those parts covered by synovial mem- 
brane they are retained. When the cartilage disappears the bone, 

Fig. 170. 




Rheumatoid arthritis. Slight superficial erosions of the bones are to be seen at several oi 
the joints. Contrast with osteoarthritis. 

deprived of its natural protection, is worn away, and under the 
influence of pressure and friction it becomes increased in density 
and hardness, " eburnated." Meanwhile the irregular projections 
of cartilage at the periphery become in part ossified, and this, 
together with a formative periostitis of the adjoining bone, causes 
the irregular bony enlargement characteristic of the disease. 



XOX-TUEEE C UL US DISEA SES OF THE JOIXTS. 2 7 7 



^.t t 



The contour of the bones and their mutual relation to one 
another are changed. The synovial membrane becomes hyper- 
trophied and its villi, some of which may contain cartilaginous 
nodules, project into the joint in shaggy fringes. These may be 
detached from time to time and may form loose bodies within the 
capsule. The synovial fluid may be greatly increased in quantity, 
distending the capsule, or, communicating with bursa?, it may form 
cysts, as is sometimes observed at the knee-joint. But more coni- 
monlv the fluid is decreased in amount. The ligaments are 
weakened and destroyed, and the tendons about the joint become 
adherent to their sheaths and to the neighboring tissues. The 
muscles atrophy and become contracted and structurally shortened 
in accommodation to the deformity. 

Etiology of Osteoarthritis. Little that is positive is known 
of the etiology of osteoarthritis. Two factors are sufficiently 
evident. These are age and injury or overstrain. The wearing 
out of the joint is suggested by the appearances, and, as is well 
known, similar changes in slight degree are not uncommonly 
found in the joints of laborers of middle age. So, also, similar 
changes may follow injury, particularly fracture at the hip-joint. 
LesseDed local and general resistance are, of course, predisposing 
causes. In locomotor ataxia, a disease accompanied by loss of 
sensation and by diminished control of movement, the nutrition 
of the joint is lowered and its natural safeguards against injury 
and overwork are removed. Joint disease (Charcot's disease) of 
the character of osteoarthritis in such instances is undoubtedly 
an indirect effect of disease of the nervous apparatus, but it by 
no means follows that such or any disease of the nervous system 
is necessary to explain the lesions of the ordinary form. Jt 
may be mentioned in this connection that a form of disease of 
similar character is very common among domestic animals in old 
age. It has been suggested, and it is probably true, that defective 
assimilation may be a causative factor in both man and animals. 

Symptoms. In its typical form osteoarthritis is an affection 
of middle life and of old age. It may be confined to a single 
joint, and in these cases one of the larger joints of the lower 
extremity is more often affected, particularly the hip or knee. 
Asa rule, however, several joints are involved to a greater or 
less degree. Its onset is usually insidious, and the progri 
slow, accompanied by remission of the symptoms. 

These symptoms are usually pain, discomfort in changing from 
one position to another, " creaking" sensations in the aff 



278 



ORTHOPEDIC SURGERY. 



joints, gradually increasing local enlargement, limitation of 
motion, and distortion of the limb. Typical examples are found 
in the hip-joint (malum coxae senile) and knee, and these are 
described elsewhere. 

Heberden's Nodosities. Although typical osteoarthritis may be 
confined to one or more of the larger articulations, it is often 
accompanied by enlargement of the joints of the fingers. It 
should be stated, also, that there is a form of osteoarthritis of 
comparatively slight importance in which the disease is confined 



Fig. 171. 




Arthritis deformans, from the Museum of the College of Physicians and Surgeons, New York. 



to the joints of the fingers. The bases of one or more of the 
distal phalanges become enlarged (Heberden's nodosities), and 
the fingers become somewhat stiff and painful. Gradually other 
phalangeal joints become involved until the fingers become 
deformed and function is somewhat interfered with. The dis- 
ease is slowly progressive, pain lessening as the enlargement 
and stiffness become more apparent. When the disease begins 
in this manner the larger joints are not often implicated. It 
is interesting to note, however, that this form of disease is far 



NON-TUBERCULOUS DISEASES OF THE JOINTS. 279 

more common in women than in men, and it may be accompanied 
by enlargements of the larger joints of the nature of rheumatoid 
arthritis (Fig. 169). 

Treatment. In general, this should be directed to the im- 
provement, if possible, of the condition of the patient ; the daily 
routine should conform to what experience shows to be that best 
adapted to the disability. The local nutrition may be maintained 
by massage, electricity, and the like. Deformity may be pre- 
vented and pain may be relieved by regulating the strain to which 
the weak part is subjected. In certain instances operative 
removal of villous proliferations of the synovial membrane or of 
solid projections that interfere with movement may be of service. 
(See Spondylitis Deformans and Osteoarthritis of the Hip and 
knee.) 

Rheumatoid Arthritis. 

Rheumatoid arthritis differs from the preceding type in that 
it is rather an affection of childhood and of early adult life than 
of old age. It is more common among females than males. It 
is more acute in its onset, more rapidly progressive, and more 
general in its distribution than osteoarthritis. 

In typical osteoarthritis the cartilage is worn away at the 
centre of the joint and heaped up at the periphery. In typical 
rheumatoid arthritis the affection is primarily of the fibrous cov- 
erings and of the membranes of the joint, and the cartilage is 
destroyed in the later stages by a pannus-like growth from the 
periphery. There is erosion of the cartilage and of the underlying 
bone unaccompanied by the hypertrophy characteristic of the pre- 
ceding disease. In rheumatoid arthritis a spindle-shaped enlarge- 
ment of the finger-joints is common, but the X-ray picture will 
not show irregular bone formation as in typical osteoarthritis 
(Heberden's nodosities), but a normal contour of the bones or 
superficial erosions entering into the formation of the joint. The 
second interphalangeal joints are usually involved primarily. 
There is usually flexion, contraction, and in many instances general 
deviation of the fingers toward the ulnar side. In younger 
subjects, particularly in the class of cases in which the onset of 
the disease is acute, and in which there is considerable effusion, 
there may be subluxation or actual luxation of the phalanges, 
more often at the metacarpal articulations. In Buch instances 
motion is preserved in the affected joints. 

In typical cases the final result in any joint is either anchylosis 
or limited motion accompanied by flexion deformity. There is, 



280 



OR Til OPED W SURGER Y. 



of course, general atrophy of the long bones in degree corre- 
sponding to the functional disability that is present. 

The onset of rheumatoid arthritis may be acute, resembling 
rheumatism, many joints being involved simultaneously. It may 
be subacute and even limited primarily to a single joint. 

The larger joints may be involved before those of the hands, 
or vice versa. In childhood the disease often begins in one of 
the larger joints, causing stiffness, deformity, and pain on motion. 
There is usually some local heat and infiltration, increasing and 
diminishing according to the strain or injury to which the joint 
may be subjected. In cases of this character the affection is 



Fig. 172. 




Rheumatoid arthritis in a child, showing the characteristic deformity. Nearly every joint 
in the body is involved. 

usually mistaken for tuberculous disease, until the involvement 
of other joints indicates the true character of the affection. As 
a rule, the affection is progressive in character, both locally and 
generally. The range of motion in the affected joint becomes 
more and more restricted, the limb becomes flexed, and, finally, 
there is practical anchylosis, usually due to adhesions and con- 
tractions within and without the joint. In those cases in which 
the cartilage is in part destroyed by the growth of granulation 
tissue from the periphery there may be actual bony union. In 
many instances the spine becomes rigid, including the occipito- 
axoid articulations, and practically every joint of the body may be 
finally involved, so that the patieut is bedridden and helpless. 



NON-TUBERCULOUS DISEASES OE THE JOINTS. 281 

The disease is more serious and more rapidly progressive in 
the young than in older subjects. There are periods of remission 

Fig. 173. 




Still's form of polyarthritis, showing the general atrophy, the enlarged joints, and the 
prominence of the stomach, due to amyloid degeneration of the liver and spleen. 

and of exacerbation. In some instances the disease appears to 
come definitely to an end, leaving the stiffened joints, and occa- 
sionally complete recovery takes place, but this is unusual. 



Fig. 174. 




The hands in the case shown in the preceding figure. 

A peculiar form of the affection, first described by Still, 1 

occurs in childhood. This begins usually in one or more of the 
larger joints. As a rule, it progresses rapidly, and it is accom- 



1 Medico-Chir. Transact!* 



282 ORTHOPEDIC SURGER Y. 

panied by enlargement of the lymphatic glands particularly those 
of the inguinal region and axilla, and of the liver and spleen. 
There is, as a rule, moderate effusion into the joints and thicken- 
ing of the overlying tissues. As the muscular atrophy is extreme, 
the joints appear by contrast very much enlarged. The final 
outcome of the disease is anchylosis and deformity, as in the 
ordinary form. Occasionally complete recovery occurs. 

Etiology. Of the etiology of rheumatoid arthritis little is 
known. Certain aspects of the disease resemble closely those 
caused by infection from without. This is particularly noticeable 
in those cases in which the disease begins in one or more of 
the larger joints. On the other hand, infectious joint disease is 
not slowly progressive, as is rheumatoid arthritis in its typical 
form. It is probable, however, that certain forms of infectious 
arthritis of a mild character are included in what is now known 
as rheumatoid arthritis. Auto-infection, due to defective assimi- 
lation, is probably a predisposing and exciting cause, as it is well 
known that this aggravates the symptoms of the disease when it 
is once established. 

Other causes are apparently lack of vital resistance due, it 
may be, to overwork or strain, mental or physical, and exposure 
to cold or wet. It may be stated, also, that some obscure affection 
of the nervous system has been assigned by certain writers as a 
probable cause. 

Treatment. In general, this must be directed to improving 
the condition of the patient by the regulation of the diet, which 
must be nourishing and easily assimilated. Exposure to cold 
and wet and overexertion must be avoided. The use of static 
electricity, the hot-air and the electric-light baths, as general and 
local stimulants are of service. Ichthyol ointment, the cautery, 
and the like may be employed locally. If the joints are sensitive 
motion should be restricted to the painless area by apparatus. 
Passive motion or massage that increases the pain or discomfort is 
harmful, but motion should be encouraged when the disease is 
quiescent. Contraction deformity may be overcome by forcible 
manipulation, and, if necessary, by tenotomy when the disease is 
quiescent. Excision of an anchylosed joint, as of the lower jaw 
or elbow, may re-establish painless motion. 

It may be noted as of interest that what appears to be typical 
rheumatoid arthritis in childhood may be induced apparently by 

i Whitman. Medical Record, April 18, 1903. 






XOX-TUBEECULOUS DISEASES OF THE JOINTS. 283 

infectious disease, such as diphtheria for example, and that 
improvement, or even disappearance of the local symptoms may 
follow intercurrent attacks of scarlatina or measles. It is possi- 
ble, therefore, that serum-therapy may be employed in the future. 
Although, as has been indicated, typical cases of rheumatoid 
arthritis differ so essentially from osteoarthritis as to be classed 
as distinct diseases, yet there are types that it is difficult to classify 
as the one or the other, and in certain instances the two forms 
may be combined in one individual. 

Haemophilia — Hemarthrosis. 

Hemorrhage into a joint may occur in a so-called " bleeder." 
In this class, which is pratically limited to the male sex, the knee- 
joint is most often involved. As a rule, it is the result of injury, 
and if the peculiarity of the patient is known the nature of the 
effusion — hemorrhagic — is hardly doubtful, particularly as there 
is in many instances discoloration of the skin, either over the joint 
or elsewhere. In some instances there is no history of traumatism, 
and the swelling may be accompanied by fever. This is probably 
the effect of the hemorrhage rather than its cause. 

The peculiar interest in the affection, aside from the importance 
of a proper diagnosis, lies in the fact that the further organiza- 
tion of the effused blood may cause symptoms and changes about 
the joint that may be mistaken for those of tuberculous disease. 
There may be, for example, persistent swelling, thickening of the 
tissues, limitation of motion, and deformity combined with more 
or less weakness and discomfort. These symptoms are explained 
by the irritation of the effused blood and by its further absorp- 
tion and organization, which necessitates the formation and growth 
of new bloodvessels ; practically, a granulation tissue is formed 
that may erode the cartilage upon which the fibrinous deposits 
rest. These secondary changes resemble the early stage of 
osteoarthritis. 

Treatment. The local treatment is rest and protection com- 
bined with stimulating applications to hasten the absorption of 
the effused blood. Several deaths have been reported from hemor- 
rhage after operative intervention in cases in which the affection 
had been mistaken for tuberculous disease. 

Hemarthrosis. 

Hemorrhage into a joint may occur in normal individuals, and 
its presence is not always indicated by superficial discoloration. 



284 



ORTHOPEDIC SURGERY. 



The swelling is more resistant than is the ordinary effusion, and 
it is far more persistent. This suggests the advisability of in- 
cision and removal of the blood clots in certain instances in order 
to relieve the joint of burden of their organization and absorption. 

Scorbutus— Scurvy. 

This affection is sometimes attended with hemorrhage into and 
about the joints. It will be considered in connection with in- 
fantile rhachitis. 

Charcot's Disease. 

Charcot's disease is a form of destructive arthritis which is 
secondary to locomotor ataxia. 

Pathology. It resembles somewhat in its pathology osteo- 
arthritis. The cartilage degenerates, and, together with the 



Fig. 175. 




Charcot's disease of tbe knee-joint. 



underlying bone, is worn away by the movements of the limb. 
Accompanying the destructive process there is an exaggerated 
and irregular formation of cartilage and bone about the periphery 
of the joint. The synovial membrane is hypertrophied, and may 



XOX-TUBEBCULOUS DISEASES OF THE JOIXTS. 285 

be covered in places with calcareous plates ; the contents of the 
joint is usually increased in quantity. 

The joint disease usually appears early in the course of loco- 
motor ataxia, often before its existence is suspected, and it is 
sometimes caused by injury. 

Charcot's disease is said to affect about 5 per cent, of the ataxic 
patients ; it is more common in the lower extremity, and one or 
more joints may be involved. In the cases tabulated by Flatow 
the distribution was as follows : 

Knee 60 ; in 13 cases both knees. 

Foot 30; " 9 " " feet. 

Hip . . . ■ . . . . 3S; *' 9 " " hips. 

Shoulder 27 : " 6 " " shoulders. 1 

Chipault 2 notes the distribution in 217 cases, as follows : 

Knee 120 

Hip 57 

Foot 40 

Fifteen cases of Charcot's disease involving the spine have 
been reported. 3 

Symptoms. The symptoms are the swelling due to the effu- 
sion, laxity of the ligaments, and deformity. There is but little 
pain, and the patient's chief complaint is of the weakness and 
distortion of the limb. In certain cases the progress of the affec- 
tion is very rapid, and the destruction of bone may be so exten- 
sive that there is an actual luxation at the affected joint. 

Diagnosis. If the patient is known to have locomotor ataxia 
the diagnosis will be evident, and in any event the peculiar 
enlargement, and thickening of the tissues, together with the 
excessive laxity of the ligaments, characteristic of this affection, 
which has been called a caricature of osteoarthritis, should call 
attention to the disease of the spinal cord. 

Treatment. The treatment of the local disease is efficient 
support to prevent progressive distortion. Excision of the knee 
has been performed, but in many cases the bones have failed to 
unite, and on this account the operation is contraindicated. 

Disease of joints secondary to other forms of disease of ike 
nervous system may occur. It is most common as a complication 
of syringomyelia, in which, in contrast to locomotor ataxia, the 
joints of the upper extremity are far more often involved than 
of the lower. 

1 Deutsche Chir., 1900, vol. 1. 2 Le Dentu et Delbet, Trait.' de Chir. 

3 Abadie. Nouv.Icon. delaSalpetriere, T. xiii., 1900. Cornell, John'- Bopkinfl Bogp. Bull., 
October, 1902. 



286 ORTHOPEDIC SURGER Y. 

In Schlesinger's cases the distribution was as follows i 1 

Shoulder 29 

Elbow 24 

Wrist 18 

Hip 4 

Knee 7 

Foot 7 

Other joints 8 

97 

In all forms of joint disease secondary to disease of the nervous 
system the influence of injury on the ill-nourished or ill-protected 
part is recognized in the causation and in the progress of the 
disease. 

This indicates the principles of local treatment. 

Anchylosis. 

Anchylosis implies fixation in an attitude of deformity, and 
the term should be restricted to practical fixation caused by tissue 
changes within or without a joint, but it is often incorrectly 
applied to limitation of motion, such as may be caused, for 
example, by muscular spasm. 

Etiology and Pathology. Anchylosis may be the result of 
actual union of two bones whose cartilages have been destroyed, 
a synostosis. This is sometimes called true, as distinguished 
from false or fibrous anchylosis. 

It may be caused by adhesions between the folds of synovial 
membrane, by adhesions and contractions of the capsular and 
other ligaments, by adhesions between the tendons and their 
sheaths, by the general adhesions and contractions caused by 
burrowing abscesses, and by the retraction and structural shorten- 
ing of muscles when the deformity has persisted for a sufficient 
time. It may be caused, also, by fractures or dislocations or by 
marginal exostoses. 

Anchylosis is usually secondary to an inflammatory affection 
of the joint during which the adhesions have formed within and 
without the capsule, and if deformity has been allowed to persist 
the muscles are atrophied and structurally shortened on the con- 
tracted side. 

Prevention and Treatment. The danger of anchylosis may 
be lessened by the proper treatment of the disease of which it 
i- a result. In tuberculous disease, for example, motion may be 
preserved in many instances by efficient protection, by which the 

1 Die Syringomyelic, Wien, 1895. 



SOX-TUBERCULOUS DISEASES OF THE JOINTS. 287 

area of the disease is restricted and its destructive effects checked. 
In this class of cases the joint should be fixed during the pro- 
gressive stage of the disease, in the attitude in which anchylosis, 
if it be unavoidable, will least inconvenience the patient, and, if 
possible, efficient traction should be employed with the aim of 
separating the surfaces of the adjoining bones. 



Fig. 17( 




A useful form of brace for weak knee, in which the range of motion is regulated by menus 
of an adjustable wheel. (Shatter.) 



Formerly it was believed that prolonged fixation of a dis< 
joint would of itself induce anchylosis, but now that it is known 
that final limitation of motion is dependent upon the .-(-verity and 
the duration of the disease, prolonged rest i- believed to !><■ tli<- 
most efficient means of assuring motion. 

In tuberculous cases, when the disease i- cured, functional use 
will ordinarily restore all the motion of which the pari is capable. 



288 



ORTHOPEDIC SURGERY. 



Fig. 1' 



In other inflammatory affections of the joint which are usually of 
infectious origin the violence of the initial process may be 
restrained by the local application of cold or heat, or by the 
removal of the contents of the joint if the infection is severe. 

In all cases the joint should be 
properly supported in order to 
relieve pain and to prevent de- 
formity. 

Passive Motion. When the 
acute symptoms have subsided 
the absorption of the plastic ma- 
terial may be hastened by mass- 
age, the hot-air bath, and the like, 
and by carefully regulated passive 
and active motion. Passive con- 
gestion after the method of Bier 
may be of service in certain cases. 
It is highly recommended by 
Blecher. 1 In the final stage, when 
there is no longer evidence of ac- 
tive disease, passive movements 
under anaesthesia may be of ser- 
vice in breaking adhesions, espe- 
cially if these are without the 
joint. Passive movements that 
cause persistent discomfort or 
pain, which are often employed in 
the treatment of stiff joints, even 
when the disease is active, are 
absolutely contraindicated. If, 
however, the limb during the 
course of the disease has become 
deformed, it should be restored 
to its proper position as soon as 
possible, even though force is re- 
quired. This treatment is indi- 
eated in order to prevent secondary retraction of the muscles and 
fasciae. 

Forcible Correction. The class of cases in which the limb has 
become fixed in deformity is the most favorable one in which 




Anchylosis at the hip, Bhowing masses of 

Dew bone. ('From the Museum of the Col- 
lege of Physicians and Surgeons.) 



Deutsche Zeits. f. Chir., Bd. lx. p. 250. 






NON-TUBERCULOUS DISEASES OF THE JOISTS. 289 

to perform the so-called briseinent force, because the rectification 
of deformity is always indicated, and in accomplishing this there is 
always the prospect of regaining a certain degree of motion. If, 
however, there is no deformity the advisability of forced movement 
will depend on the character of the preceding disease as well as 
upon the condition of the joint. It is rarely advisable to disturb 
a tuberculous joint, or at least not until long after the cure of the 
disease ; but if the anchylosis has followed infectious arthritis of 
a mild form, or monarticular " rheumatism," forcible manipula- 
tion may be attempted. If under gentle manipulation the adhe- 
sions give way suddenly, allowing free motion, the prognosis is 
good ; but if there be a peculiar, elastic, continuous resistance, as 
when there are extensive adhesions within the joint, there is little 
likelihood of attaining motion by this means. If but slight force 
has been exerted there is usually but little reaction, and massage 
and passive motion may be employed at once ; but in other 
instances the manipulation is followed by swelling and pain, 
and until these symptoms have subsided fixation may be indi- 
cated. 

Afterward, passive movements within the range that is practi- 
cally painless may be carried out manually, or by means of one of 
the so-called pendulum machines, by which the joint is moved back 
and forth at frequent intervals until the part is fatigued. Func- 
tional use, when the joint is protected by apparatus that limits the 
range of motion to the painless area, is also of service. 

The X-ray may be of value in demonstrating the condition of the 
joint and the degree of atrophy of the bones, but the history, which 
may indicate the character of the disease, and the physical exami- 
nation are far more reliable from the standpoint of prognosis. In 
some instances operative exploration of the joint may be indicated. 
This permits the removal of exostoses or displaced fragments of 
bone after fracture that may limit motion mechanically. Recently 
the attempt has been made to prevent reunion of the surfaces of 
the adjoining bones by the insertion of thin plates of magne- 
sium or other absorbable substance, as one prevents anion in 
-mailer joints by interposing muscular or other tissue in a similar 
manner. As yet the method is in the experimental stage. 

True bony anchylosis in the lower extremity admits of do 
remedy as far as the restoration of joint function Is concerned, 
although the symmetry of the limb, if it be deformed, may be 
restored by osteotomy. 

In the upper extremity motion may be restored by excision 

19 



290 ORTHOPEDIC SURGER Y. 

of the joint, and in some instances this is advisable, particularly 
for anchylosis at the elbow. 

It may be mentioned that anchylosis following disease is 
usually accompanied by marked atrophy of the bones, and frac- 
ture may occur during forcible correction. In cases of this char- 
acter the rare complication of fat embolism is sometimes 
encountered. 



CHAPTER VII. 

TUBERCULOUS DISEASE OF THE HIP-JOINT. 

Synonyms. Hip disease, morbus coxse. 

Hip disease is a chronic destructive disease that results in loss 
of function and deformity. At one time a number of patholog- 
ical processes and even simple deformity (coxa vara) were in- 
cluded under the title, but it is now limited to tuberculous disease. 

Pathology. Tuberculous disease of the hip-joint usually 
begins in several minute foci in the neighborhood of the epi- 




Section of the hip-joint at the age of eight years, showing the epiphyses and the relation ol 
the capsule. (Schuchardt.) At birth the entire upper extremity of the femur is cartllagi* 
nous. According to Jacinsky, ossification begins in the head of the femur at about the tenth 
month; in the trochanter major at from the fourth to the eighth year; in the trochanter 
minor at the eleventh year. Ossification is complete at all points at about the eighteenth 
year. 

physeal cartilage of the head of the femur. Here the circulation 
is most active, and here the newly-formed bone is least resistant. 
Thus the bacilli, carried by the blood, arc more often deposited 
at this point, where, under favoring condition-, induced it may 
be by slight traumatisms, the disease la established. Th< se foci 
coalesce and an area of infected granulations replaces the normal 



292 



OR TH OPE DIC S UR G ER Y. 



structure. If the local resistance is sufficient the disease may 
be confined to the interior of the bone, but in most instances it 
gradually forces its way into the joint, and the granulation tissue, 
spreading under and over the cartilage, destroys it in its progress. 
The lining membrane of the joint becomes involved in the dis- 
ease, and, finally, the adjoining surface of the acetabulum as well. 
In a certain indeterminate number of cases the tuberculous 

process begins about the epi- 
physeal junctions of the ace- 
tabulum, and primary disease 
of the synovial membrane may 
occur, although this is cer- 
tainly uncommon in child- 
hood. 

From the clinical stand- 
point, primary disease of the 
acetabulum may be inferred 
when the patient is particu- 
larly susceptible to movements 
of the trunk, or when lateral 
pressure on the pelvis causes 
pain ; or when a Roentgen 
picture shows greater erosion 
of the acetabulum than of the 
head of the femur (Fig. 192). 
There are other cases, in 
which the symptoms of the 
disease are slight and in which 
the swelling of the joint is 
well marked ; in such cases it 
is probable that disease of the 
synovial membrane is pres- 
ent, without marked involve- 
ment of the head of the femur or of the acetabulum. 

In the common or osteal form of disease, while the tuber- 
culous process is still confined within the head of the femur, 
the joint shows evidences of sympathetic irritation ; the synovial 
membrane is congested, and the fluid within the joint is increased 
in quantity. These changes become more marked as the disease 
progresses, the lining membrane becomes thickened and granular, 
and adhesions between its folds lessen the capacity of the joint. An 
amount of tuberculous fluid, large enough to be recognized as an 




Wandering of the acetabulum : 
(Krause.) 



in hip disease. 



TUBERCULOUS DISEASE OF THE HIP-JOIXT. 



293 



" abscess/' is present in about half the cases at some time dur- 
ing the course of the disease. This fluid usually finds an exit 
from the capsule into the tissues of the thigh, but occasionally 
it may pass through the acetabulum into the pelvis. In rare 
instances the disease may not enter the joint, but may find an 
opening in the neck outside the capsule. In such cases the joint 
is, in most instances, finally involved unless the disease is removed 
by surgical means. There are cases, also, in which the disease, 
confined within the head of the bone, so weakens it that it 
becomes distorted to a marked degree. 

Fig. ISO. 







Erosion of the head of the femur and of the upper border of the acetabulum. Formation 
of new bone (osteophytes) about the acetabulum. 

If the disease involves the neck of the bone it may sink down- 
ward, a form of coxa vara; or the head of the bone may !»<• 
separated at the epiphyseal junction, with consequent upward 
displacement of the shaft. 

In by far the larger number of cases the joint i- perforated 
and the head of the femur and the acetabulum are eroded t<» a 
greater or less degree. In such instances tli<- destructive effects 
of the disease are increased by the pressure and friction of tin* 



294 



ORTHOPEDIC SURGERY. 



softened boues on one another, aggravated by the spasm of the 
surrounding muscles. Thus at the upper margin of the acetab- 
ulum and the inner and upper surface of the femur there is 
greater loss of substance than elsewhere (Fig. 180). 

The appearances in advanced cases of this type, as seen at 
operation or autopsy, may be summarized somewhat as follows : 
The head of the femur is deeply eroded, its cartilaginous cover- 
ing has practically disappeared, or is in part still adherent in 
necrotic shreds. It lies in seropurulent fluid, embedded in the 
gelatinous necrotic granulations that line the capsule and partly 
fill the enlarged acetabulum. 



Fig. 181. 




Erosion of the head of the femur and of the upper margin of the acetabulum, 
superior spine. B, anterior inferior spine. 



A, anterior 



In certain instances the disease may extend over the adjoining 
surface of the pelvis, or the acetabulum may be perforated (Fig. 
182), or the medullary cavity of the femur may be implicated. 
Occasionally the disease may be from the first of an acute 
destructive type, whose course is but little influenced by treat- 
ment, but in the majority of cases the progress of the disease 
and its destructive effects may be greatly modified by efficient 
protection of the joint. 



TUBERCULOUS DISEASE OF THE HIP-JOINT. 



295 



In the natural cure of the disease the focus within the bone, if 
it be small, may be absorbed and replaced by scar-like tissue ; or 
the products of the disease may be separated from the healthy 
parts, and discharged by abscess formation. In other instances 
a part in which the disease is still active may be enclosed within 
the newly-formed tissue. Here the process may remain quiescent 
or it may cause relapse, many years after the apparent cure. 
Or portions of necrosed bone, enclosed within the capsule, may 
prolong suppuration after the tuberculous disease has ceased to 
progress. 

Etiology. The etiology of tuberculous disease is discussed in 
Chapter V. 

Relative Frequency. Tuberculous disease of the hip-joint is the 
most common and the most important of the affections of the 
joints, ranking second to Pott's disease. In a total of 7845 
cases of tuberculous disease treated in the out-patient department 
of the Hospital for Ruptured and Crippled during a period of 
fifteen years— 1885-1899— 3203 were Pott's disease, 2230 were 
hip disease, while the remaining 2408 cases included all the 
other joints. 

Age. Hip disease is essentially a disease of early childhood, 
although no age is exempt. In a series of 1000 consecutive 
cases of hip disease tabulated for me by Dr. D. D. Ashley, formerly 
an assistant in the department, 88.1 per cent, of the patients were 
in the first decade of life, and 45.6 per cent, of these were from 
three to five years of age, inclusive. 

Age at Incipiency. 



Less than 1 year 


. 9 


Between 16 and 17 years 


. 11 


Between 1 and 2 years 


. 39 


17 " 18 " 


4 


2 " 3 " 


. 107 


18 " 19 " 


. 5 


3 " 4 " 


. 155 


19 " 20 " 


. 


4 " 5 " 


. 158 


20 " 21 " 


. 3 


5 " 6 " 


. 139 


21 " 22 " 


. 3 


6 " 7 " 


. 90 


22 " 23 " 


1 


7 " 8 " 


. 51 


23 " 24 " 


. 2 


8 " 9 " 


. 51 


24 " 25 " 


. 3 


9 " 10 " 


. 40 


25 " 26 " 


1 


10 " 11 " 


. 33 


26 " 27 " 


. 1 


11 " 12 " 


. 19 


27 " 28 " 


. 1 


12 " 13 " 


. 18 


28 " 29 " 


. 1 


13 " 14 " 


. 23 


30 " 33 " 


4 


14 " 15 " 


. 7 


33 " 36 " 


1 


15 " 16 " 


8 


Age not stated 


. 12 



1(HK» 



Sex. Sex exercises but little influence is predisposition, 

although the disease is slightly more common anion- males 



296 



ORTHOPEDIC SURGERY. 



than among females. In the 1000 cases referred to, 553 (55.3 
per cent.) were in males, 447 were in females. 

In 3307 cases treated at the same institution, 53 per cent. 
were in males. 

Side Affected. In disease of this as of other joints the right is 
somewhat more often affected than the left. In the 1000 cases 
506 were on the right side, 483 were on the left, and in 11 cases 
both joints were involved. In a larger number of cases treated 
in the department 53 per cent, were of the right joint. 

Symptoms. Tuberculous disease of the hip-joint is a chronic, 
insidious affection characterized by occasional exacerbations of 

Fig. 182. 



41 


%mw^ 




1 




¥ 




3 





Erosion of the head of the femur and destruction of the acetabulum. 

more acute symptoms that are induced by overstrain or injury, 
by a more rapid advance of the destructive process, or by infec- 
tion with pyogenic germs. In the early stage of the disease the 
joint is simply sensitive, and the symptoms vary with the activity 
of the disease, which may increase the tension within the bone, 
the susceptibility of the patient, and the strain to which the 
weakened part is subjected. This sensitiveness is first indicated 
by the involuntary adaptation of the body to the weakness of the 
affected joint, or, as popularly expressed, the patient favors the 
leg. 

The important symptoms of disease of the hip-joint, in the 
sense of attracting attention to the affection, are pain and limp. 






TUBERCULOUS DISEASE OF THE HIP-JOIST. 297 

Of the two, pain is much the less significant. Hip disease is by 
no means a painful disease, and although patients are often 
brought for treatment because of pain, it is usually apparent, 
on examination, that the disease must have existed loug before the 
acute exacerbation called attention to its serious character. Even 
in cases in which the disease is far advanced, one may be assured 
that the patient has never complained of pain. 

Pain. The characteristic pain of hip disease is " pain in the 
knee," referred, as is the pain of Pott's disease, to the more im- 
portant distribution of the nerves, whose filaments are irritated 
by the local process. The hip-joint is supplied by the anterior 
crural, the sciatic, and the obturator nerves, but the pain is more 
often referred to the distribution of the last, thus to the inner 
side of the knee. Pain so persistently referred to the knee is 
misleading, and patients are often treated for obscure affections of 
this joint long after an examination of the hip would have made 
the diagnosis evident. 

The pain of hip disease is induced by sudden or unguarded 
movements, or by injury ; therefore, in many instances, it is 
rather an occasional than a constant symptom. Persistent pain 
almost always indicates the increased tension either within the 
bone or within the joint that accompanies abscess formation. 

Xight Cry. Pain at night is of importance, as it more often 
attracts attention than the occasional complaint of discomfort 
during the day. It is a common symptom when the disease is 
at all acute in character, and it is often present when pain, dur- 
ing the period of activity, is apparently absent. It may be 
inferred, as an explanation of this symptom, that the joint grad- 
ually becomes more sensitive under the strain of use during the 
day, and that the relaxation of the voluntary and involuntary 
protection of the muscles allows sudden movements that excite 
spasmodic muscular contractions, which force the sensitive parts 
against one another. This causes a sharp cry. If the disease 
is acute, the child is usually awakened and is found holding the 
thigh with the hands or pressing upon the limb with the other 
foot, the evidence of pain being unmistakable. In the Less sen- 
sitive conditions the patient does not wake after crying out, but 
simply moans or is restless for a time. If awakened it make- no 
complaint of pain and the cry is supposed to be caused by a • bad 
dream." This cry may be repeated several times, more often in 
the early part of the night. 

Direct local pain and sensitiveness to pressure an- unusual 



298 ORTHOPEDIC SURGER Y. 

unless the disease is acute in character, or unless the tissues 
overlying the joint are implicated, as in abscess formation. 

Limp. The limp is the most important of what may be classed 
as the preliminary signs of the disease. A limp is a change in 
the rhythm of the gait, a long step alternating with a shorter 
step. It is evident that any interference with the function of 
the limb will cause this irregularity which can be concealed or 
diminished only by accommodating the normal member to its 
disabled fellow. Thus an inequality in length, or a limitation of 
motion in the joint, or distortion, or weakness or pain, may cause 
an arrhythmical gait. Several of these factors may be combined 
in the causation of the final disability of hip disease, but in the 
beginning, the limp is due rather to sensitiveness than to any 
marked restriction of function. Thus the patient favors the 
joint by resting on the limb for a shorter time than on its fellow, 
and by bearing more weight upon the front of the foot than upon 
the heel. If the joint is very sensitive, the patient may bear 
practically all the weight upon the front of the foot, slight plantar 
flexion at the ankle being combined with slight flexion at the 
knee and hip ; thus the jar of direct impact of the heel upon an 
extended leg is avoided. 

The limp is a constant symptom of hip disease that is more 
or less noticeable according to the character of the disease ; it is 
even subject to daily variations in the same patient, being, as a 
rule, more apparent in the morning or on changing from an 
attitude of rest than during activity. The limp may be inter- 
mittent even, although it is probable that in most instances 
some change from the normal gait might be detected by a prac- 
tised eye. 

The other symptoms of disease of the hip-joint are more prop- 
erly physical signs that become evident on examination. These 
are : stiffness, distortion, change of contour of the hip, atrophy. 

Stiffness, due to reflex muscular spasm, is by far the most 
important sign of the disease. It is the instinctive expression of 
the inability of the joint to perform its full function and espe- 
cially to allow the full range of motion which puts more strain 
upon the bones and the other components of the joint. It is the 
first and the last sign of disease ; it probably precedes the limp, 
and it remains long after pain has ceased to be a symptom, and 
until repair is complete. 

Reflex muscular spasm limits motion in every direction to a 
greater or less degree. At an early stage of the disease the 



TUBERCULOUS DISEASE OF THE HIP-JOINT. 299 

motion, whether voluntary or passive, may be perfectly free 
throughout three-fourths of its normal range, but when the limit 
allowed by the muscular protection is reached motion is checked 
by a peculiar elastic resistance. If an attempt is made to force 
the limb beyond the limit set by the muscular resistance the entire 

Fig. 183. 



Apparent lengthening. Fixed abduction of 45°. When the anterior superior spines are on 
the same plane, as in the illustration, the deformity is evident. (See Fig. i • 

body follows the movement. The contraction of the surrounding 
muscles, including those of the trunk even, may be appreciated 
by the eye and by the hand, and the expression of the patient's 
face show- discomfort an<l apprehension. 

The degree of muscular spasm corresponds to the sensitiveness 
of the joint rather than to the area of tin- destructive die 



300 



ORTHOPEDIC SURGERY. 



Thus it may vary from day to day and even from hour to hour, 
and in the acute exacerbations of the disease motion may be for 
a time so absolutely restricted as to simulate anchylosis. 

Keflex muscular spasm is an infallible sign of a sensitive joint ; 
it is, of course, a symptom not confined to the tuberculous 






Fig. 184. 



Fig. 18E 





Apparent lengthening. When the dis- 
torted limb is brought to the median line 
the pelvis is so tilted that the abducted 
leg seems longer. (See Fig. 183.) 



Right-angle flexion in hip disease partly 
concealed by the compensatory lordosis and 
bv the flexion at the knee and ankle. 



process, but unless it be the direct effect of injury it indicates 
disease, and if this disease be chronic and confined to a single 
joint it is, in childhood at least, almost always tuberculous in 
character. In the early stage of hip disease the restriction 
of motion is caused almost entirely by reflex muscular spasm, as 






TUBERCULOUS DISEASE OF THE HIP-JOINT. 301 

is shown by the fact that when the patient is anaesthetized the 
range of motion becomes practically free. As the destructive 
process progresses motion is still further restrained by adhesions 
and contractions within and without the joint. 

Distortion of the Limb. Persistent reflex muscular spasm is 
always accompanied by a certain change in the attitude of the 
limb, slight flexion being the earliest indication of distortion in 
disease of the hip, as at every other joint. With this flexion 
there is usually abduction and slight outward rotation of the limb. 

Flexion, Abduction, and Outward Rotation. Appar- 
ent Lengthening. This is the passive attitude or the attitude 
of rest in the normal condition, and in disease it shows the 
instinctive adaptation of the limb to a sensitive joint which is 
still capable of a certain amount of work. The flexion lessens 
the direct jar and the abduction throws the limb aside, as it were, 
from the active attitude, making it a prop and adjunct of its 
fellow instead of an active aid in the propulsion of the body. 
This attitude is not voluntarily assumed by the patient ; it is 
involuntary and persistent. The limb is apparently lengthened, 
because it is held away from the axis of the body, and in order 
to bring it into the middle line and parallel to its fellow the 
pelvis must be tilted downward on the diseased side and upward 
on the other. The sound leg is drawn upward and the affected 
leg is lowered according to the degree of abduction (Fig. 184). 
If, however, the anterior superior spines of the pelvis be placed 
upon the same plane, the distortion becomes evident (Fig. 183). 
Thus the deformity of the limb is concealed or compensated by a 
tilting of the pelvis which twists the lumbar spine into a lateral 
convexity toward the lower side. 

In the same manner persistent flexion of the leg is concealed 
by a tilting of the pelvis forward, and by an increased hollow - 
ness or lordosis of the lumbar region (Fig. 185). Normally, in 
childhood at least, the lumbar spine and the popliteal surface of 
the knee should touch the table when the patient lies upon the 
back, but if the thigh is fixed in flexion the lumbar region must 
be arched and raised from the table when the leg rests upon it. 
Thus, in order to make the flexion apparent, the Lumbar spine 
must be forced to touch the table, and this la possible only when 
the limb is raised to a degree corresponding to the deformity 
( Fig. 186). If the spine were rigid, as in spondylitis deformans, 
this compensation would be impossible, and if the patient were 
placed upon his back the leg could aoi be brought down to the 



302 



mrruoPEDic surgery. 



table ; or if both limbs were distorted, as is sometimes the case 
when both hip-joints are diseased, the limbs would remain widely 
separated or crossed over one another, according to the character 
of the deformity. 

Flexion, Adduction, and Inward Rotation. Apparent 
Shortening. If the disease is of a more acute type, and if 
locomotion be permitted, the attitude usually changes to one of 
increased flexion, and adduction and inward rotation replace 
abduction and outward rotation. This attitude is an indication 
that the joint is so disabled as to be of little use, thus the limb 
is instinctively drawn into a more protected attitude where it 
may be used as little as possible. If the patient is confined to 
the bed, or does not walk, as in hip disease in infancy, the atti- 



Fig. 186. 



^1 


^™#e ; * v! 








1 


^ 

3 






2 




- 




















^B<^9 



The degree of fixed flexion is shown when the lumbar spine is held in contact with the table 
by flexing the other thigh. 



tude of abduction may persist, although the muscular spasm may 
be intense. Thus it would appear that locomotion has a distinct 
influence on the character of the distortion. 

Adduction causes apparent or practical shortening; for in 
order to bring the adducted limb to the middle line of the body 
and parallel with its fellow, the pelvis must be tilted upward on 
the affected side and downward on the other, the lumbar spine 
bending with the convexity toward the lower side (Figs. 188 and 
l!'l i. If the level of the pelvis be restored, the adducted limb 
will be crossed over its fellow, and the deformity is made evident 
(Fig. 1X7,. 

As has been stated, the attitude of flexion, adduction, and 
inward rotation, if it appears early in the disease, is usually an 



TUBERCULOUS DISEASE OF THE HIP-JOIST. 



303 



indication of acute and disabling pain and of corresponding in- 
tensity of muscular spasm. But in most instances it is associated 
with the later and destructive stage of the disease, and it by no 



Fig. 1S7. 



Fig. 18S. 




Apparent shortening. The adduction of the 
right thigh is made evident by the involun- 
tary crossing of the legs when the anterior 
superior spines are on the same plane. 



Apparent shortening. When the adducted 
limb is placed in the line of the body, the 
pelvis is tilted upward on the adducted side 
and downward on the other. The patient has 
compensated for the apparent shortening by 
flexing the knee on the sound side. 'Un- 
does not appear in the photograph. 



means indicates that the preceding symptoms have been more 
than ordinarily acute. In fact, it is the attitude characteristic 
of a so-called "natural cure" (Fig. 189) when mechanical treatr 
menthas'not been employed. It more often accompanies the 



304 



ORTHOPEDIC SURGERY. 



Fig. 189. 



later course of the disease, because its causes are in great degree 
mechanical. 

This is illustrated by Koenig's statistics of 499 cases of hip 
disease. 

In 267 cases the limb was abducted, and in 31 per cent, of 
these there was actual shortening. 

In 232 cases adduction was pres- 
ent, and in 70 per cent, the limb was 
shorter than its fellow. 1 

The mechanics of the distortion 
will be made clearer if it be com- 
pared to the deformity symptomatic 
of dorsal dislocation of the hip. In 
this displacement the femur, forced 
upward and backward upon the pel- 
vis, is fixed in an attitude of extreme 
flexion, adduction, and inward rota- 
tion. Each of the destructive changes 
of hip disease, the enlargement of 
the acetabulum, the depression of 
the neck of the femur, and the ero- 
sion of the head of the bone, is ac- 
companied by an elevation of the 
femur upon the pelvis or an approxi- 
mation to a dorsal displacement (Fig. 
190). If this displacement occurs 
suddenly, as in certain cases of acute 
disease attended by effusion and 
rupture of the capsule, the limb im- 
mediately assumes an attitude typical 
of dorsal dislocation ; but in the or- 
dinary form of disease the changes 
are very gradual ; the pelvis and 
the femur, being in most instances 
undeveloped, more easily accommo- 
date themselves to the changed con- 
ditions, so that the actual distortion 
is less marked than in a similar sub- 
luxation of traumatic origin in the adult, but the simile will 
serve to illustrate the mechanical causes of distortion, and why 




The final effect of hip disease when 
untreated. The natural cure, with 
flexion and adduction. Compensatory 
recurvation of the knee on the sound 
side is also shown. 



1 Koenig. Das Hoeftgelenk, Berlin, 1902. 



TUBERCUL US BISEA SE OF THE HIP -J INT. 



305 



such deformity may recur after correction, even though the disease 
has entirely disappeared. 

Outward rotation of the limb is usually associated with abduc- 
tion, and inward rotation with adduction, but in certain instances 



Fig. 190. 



Fro. 191. 





Untreated hip disease. Flexion 
deformity to nearly a right angle 
with the body. Trochanter two 
inches above Nelaton's line. Com- 
pensatory lord 



Stage of apparent shortening. The left limb 
is adducted 35°, making an apparent shortening 
measured from the umbilicus of more than two 
inches. In order to reduce the obliquity of the 
I>elvis, the adducted leg must be croi 
fellow. (See Fig. 187.) The apparent shortening 
is compensated by the flexion at the k 
the sound side. This is not made clear in the 
photograph. 



outward rotation may be combined with adduction and met versa. 
These irregular attitudes are more often observed in cases thai 



306 



ORTHOPEDIC SURGERY. 



have received mechanical or operative treatment than in those 
in which the disease has pursued its natural course. 

As has been stated, the distortions of the early course of hip 
disease are caused almost entirely by muscular contraction which 
relaxes under the influence of an anaesthetic, but after a time the 
attitude is still further assured by accommodative changes in the 
muscles and fasciae, and by contractions and adhesions about the 
capsule. Thus an attitude that was originally a symptom may 
persist after the cure of the disease. 

One may conclude then that flexion is practically an invari- 
able symptom in hip disease because complete extension, the 
attitude that puts most strain upon the joint, is first restricted. 
Flexion in the milder or in the earlier class of cases is usually 
combined with abduction and outward rotation, the attitude of 
inactivity. Increased flexion, accompanied by adduction and 
inward rotation in the early stage, is an indication of a more 
acute phase of the disease. If the attitude is retained for a time 
it becomes fixed by accommodative changes in the tissues ; thus 
the distortion is not unusual in cases in which the damage to the 
joint may be very slight, as, for example, when it follows rheu- 
matism or some form of infectious arthritis. But in most in- 
stances the attitude is indicative of more advanced disease and of 
destructive changes within the joint. 

Changes in the Contour of the Hip. In the early stage of the 
disease the changes in contour are caused in great part by the 
attitude of the limb. If, as is usual, it is flexed, abducted, and 
rotated outward, the buttock appears somewhat flatter and broader 
than its fellow. The gluteofemoral fold is lower because of the 
tilting downward of the pelvis and it is shallower because of the 
flexion. If the thigh is adducted, the gluteal fold will be ele- 
vated and shortened. On the anterior aspect, the inguinofemoral 
fold is deepened and lengthened by flexion and adduction, while 
abduction makes it less noticeable. Hoffman has called attention 
to the fact that the genitals and the intergluteal fold point toward 
the adducted and away from the abducted thigh. Adduction 
makes the trochanter more prominent, and abduction makes it 
less prominent. 

To these primary changes in the appearances must be added 
the effect of atrophy or of infiltration and swelling, due directly 
to the disease. A certain amount of swelling indicating effusion 
into the joint is often apparent in the inguinofemoral region, and 
infiltration of the deeper tissues is sometimes evident on palpation. 



TUBERCULOUS DISEASE OF THE HIP-JOINT. 3Q7 

In such cases there is usually a certain sensitiveness to deep pressure 
behind or in front of the trochanter. Palpable or evident abscess 
is unusual in the early stage of the disease. 

Atrophy. Atrophy is an important sign of joint disease. It is 
often appreciable to the eye and to the hand, and it is always 
demonstrable by measurement. It is an important symptom, 
because, if well marked, it shows that the disease must have 
existed for some time, whatever may be the statement of the 
patient's relatives. 

The atrophy affects the muscles of the entire limb, although it 
is somewhat more marked in the muscles of the thigh than in 
the calf. In the ordinary case of hip disease in childhood, when 
the patient is first brought for treatment, it averages from one- 
half to one inch in the thigh and somewhat less in the calf. As 
has been stated elsewhere, atrophy of muscles is usually accom- 
panied by a corresponding atrophy of bone as well. 

The Causes of Atrophy. The causes of the atrophy 
secondary to joint disease have been the subject of much discus- 
sion. As it is associated with an increase of the reflex excita- 
bility of the muscles, and as it often progresses with great rapidity, 
the prevailing theory has been that of Vulpian and Charcot, that 
it is of nervous or reflex origin. According to this hypothesis 
the atrophy is the result of a change in the trophic centres of the 
spinal cord, " an inertia," due to irritation of the articular fila- 
ments of the nerves. 

Another theory has been advanced by Saborin. As branches 
of the same nerves are distributed to the joint and to the sur- 
rounding muscles, he suggests that the atrophy may be caused by 
a direct implication of the nerves whose filaments are involved in 
the disease of the joint — a form of molecular neuritis. 

Admitting that the secondary causes of atrophy are souk what 
obscure, one cause, and by far the most important, is very evi- 
dent. This is physiological disuse, and thus diminished nutrition 
of the limb which has become incompetent to carry out its full 
function. Atrophy is a constant symptom of simple disuse in 
the absence of disease. If a bone has been broken, atrophy of 
the surrounding muscles is observed. If anchylosis of a joint 
occurs from any cause, whether it be from injury or du 
atrophy of the muscle-, whose function lias been abolished, fol- 
low-. Even the atrophy caused by disease of the hip-joint is 
greater when the limb has been fixed in apparatus than when 
none has been applied, although the treatment has allayed the 



308 ORTHOPEDIC S UEQ EB Y. 

l>ain and has checked the progress of the disease. This point is 
illustrated by the observations of Brackett, 1 who contrasted the 
atrophy of hip disease in two groups of patients, in one of which 
motion had been permitted, while in the other fixation, as com- 
plete as possible, had been employed. In the first group the 
average of atrophy was but 1 per cent, of the volume of the 
thigh and 0.89 per cent, of that of the leg, as contrasted with 
23 per cent, and 17 per cent, in the second class. 

It has been stated in objection to this theory, by those who 
understand disuse as meaning only relief from motion and 
weight bearing, that atrophy is observed even though the patient 
be confined to the bed, but under these conditions there would 
be relative disuse of a limb if motion caused pain or discomfort, 
in degree proportionate to the intensity of the local disease. 
Meanwhile a lesser atrophy might be demonstrated in the sound 
limb that had been deprived of its normal stimulus, just as 
relative hypertrophy of a limb which has to perform double 
function is often observed. 

The atrophy caused by physiological disuse and diminished 
nutrition affects all the components of the limb. The skin 
becomes thinner, the muscles lose in volume, the contractile sub- 
stance is replaced in part by fat and by fibrous tissue, and the 
medullary canals of the bones enlarge at the expense of the 
cortical substance. 

In childhood, the period of rapid development, disuse often 
causes a retardation in growth of the entire extremity. This 
may be apparent in the foot when it is placed by the side of its 
fellow, while the diminished growth in the length of the limb 
may be demonstrated by measurement. Brackett, in a series of 
cases, found this shortening to be distributed as follows : average 
• loss of the femur 6.6 per cent, and of the tibia 5.4 per cent, of 
the normal length. 

This atrophy, the direct result of the disease and of the long- 
continued disuse during the period of repair, becomes less notice- 
able after function is resumed, the degree of final inequality 
depending upon the severity of the disease, the duration of the 
treatment, and upon the impairment of function. But even 
when free motion in the joint is retained, a certain amount of 
atrophy always persists and the loss in growth is never replaced. 
If motion is completely abolished the muscles about the joint lose 

' Transactions American Orthopedic Association, vol. iv. 



TUBERCULOUS DISEASE OF THE HIP-JOINT. 



309 



in bulk in proportion to the disuse of their normal function ; where- 
as, the bones of the limb which are still used to support the weight 
retain to a greater degree their normal size and length. Combined 
with the atrophy of the weak limb there is a relative hypertrophy 
of the sound les; which is forced to assume more than its share of 
work. 

Fig. 192. 




Early stage of disease of the left hip-joint (to the right in the picture) of the synovial type, 
showing irregularity in the shape of the acetabulum. 

Actual Shortening. Actual shortening of the limb i- a 
C immon effect of hip disease, but it can hardly be called a symp- 
tom, for it is aot present at the onset of the disease. 

The causes of actual shortening may be classified as : 

1. Disuse of the limb. 

2. The effect of the disease upon the epiphysis of the head of 
the femur. 



310 



ORTHOPEDIC SURGERY. 



3. The more general destructive effects of the disease that 
cause upward displacement of the femur. 

(a) Erosion of the head. 

(b) Erosion of the acetabulum. 

(c) Depression of the neck of the femur. 

Disuse, throughout a long period of treatment, may cause a 
certain amount of shortening of the entire limb. To this the 

Fig. 193. 




Advanced disease, showing wandering of the acetabulum and the obliquity of the pelvis due 
to adduction. Actual shortening one inch, apparent shortening three inches. 

shortening of the bones of the leg and of the foot may be 
attributed in great part. If the epiphysis of the head of the 
femur is destroyed in whole or in part or if the disease hastens 
its union with the neck a certain loss of growth must follow. 
This is, of course, slight in degree, because this epiphysis is 



TUBERCULOUS DISEASE OF THE HIP-JOINT. 



311 



relatively unimportant compared with that at the lower extremity 
of the femur. From these two causes, the atrophy of disuse and 
the effect of the disease upon the epiphysis, relative shortening 
of the limb may increase after the disease is cured. 

Erosion of the head of the femur and of the upper border of 
the acetabulum are usually combined in those cases in which the 
shortening is in part dependent on upward displacement of the 
trochanter (Fig. 180). Depression of the neck of the femur to 
an appreciable degree is less common. Elevation of the trochan- 
ter, due to one or more of these causes, a form of subluxation, 
is very common, particularly so in those cases in which the pro- 
tective treatment has been inefficient. Greater displacement 
follows fracture of the weakened neck and complete absorption 
of the head, and occasionally a fairly normal femur may be 
actually dislocated as a result of sudden effusion into the joint 
with rupture of the capsule — a form of pathological dislocation. 

Retakdation of Growth. As has been stated, all the com- 
ponents of the limb are affected by the retardation of the growth. 
Brackett's observations on this point have been mentioned, and 
the accompanying table, showing the relative measures of the 
bones in cases under treatment by Dollinger, 1 of Budapest, presents 
the subject in a convenient form : 





Age at 


Duration of 


Length of 




Length of 






inception. 


disease. 


femur in cm. 




tibia in cm. 




No. of 






Differ- 
ence. 




Differ- 


case. 






Years. Months' J 1 ^ Normal 


Dis- 
eased. 




ence. 




Years. 


Months 




Normal 




1 


8 


6 




6 


283^ 28 


+V* 


24 


24 




2 


3 


4 




8 


23 24 


1 


19 


19 




3 





10 


"i 


8 


24 24 




19.5 


19.5 




4 


5 




2 




29 


30 


"i 


23.5 


23.5 




5 


6 




2 




27 


28 


i 


23 


23 




6 


7 




2 




32 


33 


i 


27 


27 




7 


9 




2 




37 


37 




30 


30 




8 


1 


4 




22 


24 


*2 


18.5 


19 


0l*5 


9 


13 




4 




38 


41 


3 


34 


34 




10 


4 


6 


5 




32 


34 


2 


27 


27 




11 




V/2 


6 




26 


27 


1 


21^ 


23 


i" 


12 


13 




7 




38 40 


2 


33 


84 




13 


2 




8 




35 36 


1 


28 


28 




14 


6 




8 




38 38 




31 


32 




15 


11 


... 


8 




40 44 


"i 


34 


:>.i 




16 


5 




10 




45 46 


i 


... 






17 


5 




11 




41 44 


3 


31 


37 




18 


6 




14 




44 IS 


4 


36 


39.5 


8. 5 




2 




18 




36 46 


10 


38 


38 




20 


2 




28 


"' 


44^ 45 


H 


37.5 







A similar investigation of thirty-three cases under treatment 
at the Hospital for Ruptured and Crippled, New York, baa been 
made recently by Taylor. In these cases the shortening of the 



Zeits. f. Orth. Chir., 1892, Bd. I. 



312 



ORTHOPEDIC SURGERY 



hones was found to be more generaly distributed than in those 
reported by J V>1 linger, as is illustrated by the following table : 





Sex. 


Age. 


Side. 


Dura- 
tion of 
disease, 
years. 


Dura- 
tion of 
treat- 


Abscess 


Shortening in inches. 


Case. 




















ment, 
years. 




Entire 
limb. 


Femur. 


Tibia. 


Foot. 


Patella. 


1 


F. 


Stf 


Left 


1 


1 


No 


A 


_ 


8 


y 8 


A 


2 


M. 


7 


Right 
Left 


1A 


1 


No 


A 

Vs 


X 


% 


y 


3 


M. 


5 


2 


1 


No 


Va 


M 


A 


% 


4 


M. 


5 


Right 


2 


1A 


No 


% 


Y 


% 


% 


5 


M. 


6% Lett 


*A 


1^ 


Yes 


% 


A 


3/8 


Vs 


Y 


6 


F. 


4H Left 


3 


3 


No 










Ya 


7 


F. 


6X 2 Right 


3 


— 


No 


V* 


— 


S 


— 




8 


M. 


6 Right 





*A 


No 


& 


Y 


A 


3/8 

A 


9 


F. 


13 iLeft 


*A 
3V 2 


2 


No 




^ 


% 


10 


F. 


7 ILeft 


3^ 


No 


% 


3 /l 


% 


Y 


11 


M. 


7 Right 


3K 


*A 
^ l A 
VA 


Yes 


l 


X 


Ya 


Vs 


12 


F. 


11 Right 


3V 3 


No 


IS 


Y 


3 


Y 


% 


13 


F. 


9 Left 


sk 


No 




A 


Average 


7 




2V 2 


2 




Va 


Va 


A 


Y 


A 


14 


M. 


7 


Right 


4 


4 


No 


1 


Va 


Y 


Ya 


% 


15 


F. 


&A Right 


4 


4 


No 


1 


Y 


% 


Va 


16 


F. 


12 Right 


5 


4 


Yes 


3 1 / 


A 


lY 


H 


X 


17 


F. 


11 


Right 
Left 


*A 


4 


Yes 


2 1 / 


l 


A 


Y 


Y 


18 


F. 


13 


6 


3 


No 


2 


A 


1% 


A 


Y 


19 


F. 


12 


Left 


6 


4 


No 


% 


-4 


U 


Vs 


Vs 


20 


F. 


10 


Left 


C% 


4 


No 


W* 


A 


Y 




Va 


21 


M. 


14 


Left 


7 


X 


Yes 


2A 


X 


Va 


A 


Va 


22 


F. 


15 


Right 


7 


5 


No 


2M 


X 


1 


X 


23 


M. 


9^ Right 


7 


A 


Yes 


IY 


— 


A 


A 


X 


Average 


11 ! 


5K 


W 2 




m 


A 


Va 


A 


Vs 


24 


F. 


13 Right 


8 


7 


Yes 


w 


Y 


*A 


1 


Ya 


25 


M. 


15 Right 


9 


6 


Yes 


ty* 


2 


Wa 


X 


X 


26 


M. 


10K Right 


9 


X 


No 


IK 

2% 


A 


Vs 


Y 


a 


27 


F. 


18 Right 


9 


7 


No 


X 


1 


A 

% 


28 


M. 


18 Right 


11 


10 


Yes 


2 


% 


1 


X 


29 


F. 


15 Left 


11 


7 


Yes 


3 


Va 


Vs 


Y 


1 


30 


F. 


15 Right 


11 


5 


Yes 


1 


Ya, 


Ya 


if 


31 


F. 


15 Right 


UK 


9A 


Yes 


3 


Va 


Ya 


8 


32 


F. 


16 Left 


14 


1 


No 


13^ 


*A 


Ya 


33 


F. 


21 


Left 


17 


6 


Yes 


5K 


v/ 2 


Va 
A 


H 


Ave 


rage 


15 




11 


6 1 


2K 


Vs 


1 


* 



— Measurements equal. x Measurements not taken. 

Measurements of the femur from the apex of the great trochanter to the knee-joint. Patella 
measured transversely. The cases are grouped according to the duration of disease and the 
averages are given separately for each group. 

Dr. Taylor measured also ten cases of unilateral poliomyelitis, 
in patients of an average age of thirteen years, with an average 
duration of disability of ten years. The average shortening in 
these cases was one and three-fourths inches, and in no case was 
it greater than two and one-half inches. It will be noted that 
the retardation of growth in this group corresponds closely with 
that of the third group of cases of hip disease, in which the disa- 
bility was of about the same duration. Taylor concludes that 



TUBERCULOUS DISEASE OF THE HIP-JOIXT. 31 3 

the retardation of growth from unilateral hip disease in childhood 
is dependent in great degree upon the duration of the disability 
and upon the corresponding restraint of function. Similar 
observations on fifty cases of hip disease have been recorded by 
Hibbs. 1 In eleven of these cases the femur was found to be 
slightly longer on the diseased side. 

Actual lengthening of the limb as the result of disease is 
occasionally observed during the active stage of the disease, 
caused it may be inferred by granulations within the acetabulum 
that press the femur outward and downward. Actual lengthen- 
ing of the femur is uncommon, but it does occur, induced, it may 
be, by stimulation of the growth of the epiphysis of the head ; 
but the most extreme instances are those in which the upper por- 
tion of the shaft of the femur is involved, the lengthening beiug 
the effect of an irritative hypertrophy. This is more commonly 
the result of extra-articular disease. 

General Symptoms of the Disease. Debility. If the disease 
is sufficiently painful to cause loss of sleep and to affect the 
appetite, pallor and loss of flesh and strength may be expected. 
It must be borne in mind, however, that the patient may have 
been " delicate " long before the local tuberculous disease was 
acquired. At all events, from the diagnostic standpoint at least, 
the local disease has no characteristic influence upon the general 
condition, and the appearance of perfect health is not at all 
unusual among patients with hip disease. 

Fever. It is probable that a slight elevation of temperature 
might be detected in a large proportion of the patients, and in 
such cases actual appreciable fever often follows overexertion or 
injury. Fever, as a symptom of infected abscess in the later 
course of the disease, is, of course, of importance, but in the early 
stages of the disease the record of the temperature would be of 
but little diagnostic value. 

The History and the Method of Examination. In consider- 
ing the differential diagnosis of tuberculous disease of the hip- 
joint one should keep its characteristics in mind. It is a chronic 
disease, in that the symptoms may have been present for weeks 
or months or even years before the patient is brought for treat- 
ment It is a disease confined to a single joint, thus differing 
from rheumatism and similar affections in which several joints 
are involved. It does not get well ; thus it may he differentiated 
from injury and from the minor affections that simulate some <>f 

1 New York Medical Journal, December 10, I 



314 OB THOPED IC S UEGER Y. 

its symptoms. It causes a limp. It is accompanied by reflex 
muscular spasm, usually by a certain amount of deformity and 
by general atrophy of the muscles of the limb. 

The importance of the inheritance and of the personal history 
of the patient has been mentioned already in the consideration 
of Pott's disease. In recording the history in this as in all 
other chronic diseases of childhood one attempts to ascertain the 
approximate duration of the pathological process rather than the 
duration of the more acute symptoms for which the patient has 
been brought for treatment. One asks, therefore, when the child 
was last perfectly well, and, bearing in mind the remission of 
symptoms, one asks if limp or pain had been noticed at any time 
before the more acute symptoms. In the history there is almost 
invariably mention of a fall, and one must ascertain whether the 
fall had any influence in the causation of the symptoms, remem- 
bering that the weakness and interference with function due to 
joint disease more often cause falls than falls cause joint disease. 

Physical Examination. One begins the physical examination by 
the observation of the general condition of the patient, and notes 
the attitudes, and the character of the limp. The patient's cloth- 
ing is then entirely removed, that one may observe the contour 
of the part and the general influence of the affection upon the 
mechanism of the body. The patient is then placed on his back 
upon a table, with the limbs parallel to one another, so that 
their relative length and size may be observed. If the pelvis is 
level when the limbs are parallel, there caki be no persistent 
abduction or adduction, for when the two anterior superior spines 
are on the same plane such distortion is always evident. If the 
lumbar spine and the popliteal surfaces of the knees rest on 
the table simultaneously it shows, too, that persistent flexion is 
absent. One next tests the functions of the hip-joints, always 
beginning with the sound side for the purpose of comparison, 
and in order that the patient may become accustomed to the 
manipulation before the one suspected of disease is tested. Dis- 
ease within a joint is accompanied by muscular spasm that limits 
motion in every direction, thus differing from other affections 
outside the joint that may limit its motion in one or more but 
not in all directions. 

One compares the flexion, abduction, adduction, and rotation 
of the Limbs while the child lies upon its back ; it is then turned 
upon its face to test for extension by holding the pelvis flat upon 
the table with one hand while the thigh is gently elevated with 



TUBERCULOUS DISEASE OF THE HIP-JOIST. 315 

the other (Fig. 16). The normal range of extension in child- 
hood is at least ten degrees backward from the line of the body, 
and limitation of this range is the earliest sign of approaching 
deformity of hip disease. It may precede the restriction of the 
extremes of motion in other directions, although this is unusual, 
and if this motion is unrestricted disease of the joint may be, 
practically speaking, excluded. The character of the reflex 
spasm that limits motion and the indications of discomfort when 
the limit has been reached have been described. 

Measurements. The measurements of the limbs are then made. 
One first ascertains the actual length of the limbs by measur- 
ing from the anterior superior spines of the pelvis to the extrem- 
ities of the internal malleoli, actual shortening being, of course, 
absent in the early stage of the disease. The second measure- 
ment is from the umbilicus to show the amount of apparent 
shortening or lengthening that may be present if the limb is dis- 
torted. The actual length of the limbs, as measured from the 
anterior superior spines, is not changed by tilting of the pelvis, 
but as the umbilicus is in the middle line of the body above the 
pelvis, measurement from this point simply shows the actual dis- 
tance to the malleoli. Persistent adduction causes compensatory 
obliquity of the pelvis ; consequently the malleolus on the affected 
side is drawn upward or nearer to the umbilicus, while the other 
is carried downward to a corresponding distance (Fig. 191). If, 
then, the measurements from the umbilicus to the malleoli do not 
correspond relatively with those from the anterior superior spines, 
when the limbs are parallel and in the median line, it shows 
distortion : adduction, if the limb is relatively shorter, abduction, 
if it is relatively longer than is shown by the measurement from 
the anterior superior spine. It has been stated that the meas- 
urement from the anterior superior spine is not changed by dis- 
tortion. It is, however, shortened slightly by outward rotation, 
and more appreciably by abduction, and it is lengthened some- 
what by adduction. This is explained as follows : When the 
limb is in the line of the body the trochanter is below the ante] tor 
superior spine from which the measurement is made. Abduction 
of the limb raises the trochanter toward the plane of the anterior 
superior spine, and consequently lessens the distance from this 
point to the extremity of the limb. Adduction, on the contrary, 
lowers the trochanter and increases the distance between these 
two points. Tn ordinary cases the variation from this source 
does not exceed half an inch. Flexion of one thigh can-.- a tilt- 



316 



ORTHOPEDIC SURGERY. 



inir forward of the pelvis that lessens the distance between the 
anterior superior spine and the malleolus on both sides, although 
not to an equal degree. It is customary, therefore, if the flexion is 
considerable, to raise the unaffected limb to the line of its fellow 
in making the comparative measurements, stating in the record 
that the limbs have been measured at the angle of the deformity. 
Method of Estimating the Degree of Distortion of 
the Limb. As has been stated, when the pelvis is level, distor- 
tion of the limb is apparent, and the degree of distortion can be 
measured by the goniometer (Fig. 187); but it may be more 
easily ascertained by " Lovett's table. m This method is described 
by its author as follows : 

Table I.— Distance between Anterior Superior Spines in Inches. 





3 


3^ 4 


4K 


5 5}i 


6 


6^ 


7 


iy\ 


8 


sy 2 


9 


9% 


10 


11 


12 13 


bO 

p 

I 

J3 


' Vx 


5° 


4° 


4° 


3° 


3° 


2° 


2° 


2° 


2° 


2° 


2° 


2° 


2° 


1° 


1° 


1° 


1° 1° 


% 


10 


8 


7 


6 


5 


« 


4 


4 


4 


4 


4 


4 


4 


3 


3 


3 


3 


2 


% 


14 


12 


11 


10 


8 


8 


7 


7 


6 


6 


5 


5 


5 


4 


4 


4 


3 


3 


■r. 

C 


1 


19 


IT 


14 


13 


11 


10 


9 


9 


8 


7 


7 


7 


6 


6 


6 


5 


5 


4 




15* 


25 


21 


18 


16 


14 


13 


12 


11 


10 


9 


9 


8 


8 


7 


7 


7 


6 


6 


- 


1% 


30 


25 


22 


19 


17 


15 


14 


13 


12 


12 


11 


10 


10 


9 


9 


8 


7 


7 




Wx 


36 


30 


26 


23 


20 


18 


17 


15 


14 


13 


13 


12 


11 


10 


10 


9 


8 8 


"3 


2 


42 


35 


30 


26 


23 


21 


19 


18 


16 


15 


14 


14 


13 


12 


12 


10 


10 9 


a 
1 

s 

— 


V/a 




40 


34 


30 


26 


24 


21 


20 


19 


17 


16 


15 


14 


14 


13 


12 


11 10 


2% 




... 


39 


34 


29 


27 


24 


22 


21 


19 


18 


17 


16 


15 


14 


13 


12 11 


2H 








38 


32 


29 


27 


25 


23 


21 


20 


19 


18 


17 


16 


14 


13 12 


3 








42 


35 


32 


29 


27 


25 


23 


22 


21 


19 


18 


18 


16 


14 12 


= 


3K 










39 


36 


32 


30 


27 


26 


25 


22 


21 


20 


19 


17 


15 14 


c 


sy 3 


... 










40 


35 


33 


30 


28 


26 


24 


23 


22 


21 


19 


17 16 




ZH 














38 


35 


32 


30 


28 


26 


25 


23 


22 


20 


18 17 


5 


I 4 














42 


38 


35 


32 


30 


28 


26 


25 


23 


21 


19 18 



" To measure by this method the patient is made to lie straight 
with the legs parallel. Real shortening is measured with the 
ordinary tape measure, and apparent shortening is obtained in 
the same way. It may be repeated that real or bony shortening 
is measured from the anterior superior iliac spines to each mal- 
leolus, and that practical shortening is found by a measurement 
taken from the umbilicus to each malleolus. The difference in 
inches between the two kinds of shortening is seen at a glance. 



R. W. Lovett. Boston Medical and Surgical Journal, March 8, 1888. 



TUBERCULOUS DISEASE OF THE HIP-JOINT. 31 7 

The only additional measurement necessary is the distance 
between the anterior superior spines, which is taken with the 
tape. Turning now to the table : if the line which represents 
the amount of difference in inches between the real and apparent 
shortening is followed until it intersects the line which represents 
the pelvic breadth, the angle of deformity will be found in 
degrees where they meet. If the practical shortening is greater 
than the real shortening, the diseased leg is add acted ; if less than 
real shortening, it is abducted. Take an example : Length 
(from anterior superior spine) of right leg, 23 ; left leg, 22 J ; 
length (from umbilicus) of right leg, 25 ; left leg, 2o ; real 
shortening, J inch ; apparent shortening, 2 inches ; difference 
between real and practical shortening, 1 J inches ; pelvic meas- 
urement, 7 inches. If we follow the line for H inches until it 

Fig. 194. 



A C 

Kingsley's method of estimating flexion. 

intersects the line for pelvic breadth of 7 inches, we find 12° to 
be the angular deformity, as the practical shortening is greater 
than the real, it is 12° of adduction of the left leg. If apparent 
lengthening is present its amount should be added to the amount 
of actual shortening." 

If flexion is present the degree may be ascertained by raising 
the flexed limb until the lumbar spine touches the tabic when the 
angle formed by the thigh with the body may be measured with 
the goniometer (Fig. 186), or its degree may be ascertained by 
Kingsley's table. 

" The patient lies upon a table flat on his back and the surgeon 
flexes the diseased leg, raising it by the fool until tin- Lumbar 
vertebra? touch the table, showing that the pelvis is in tin- correct 
position. The le^r i- then held for a minute at that angle, the 



318 ORTHOPEDIC SURGERY. 

knee being extended, while the surgeon measures off two feet on 
the outside of the leg with a tape measure, one end of which is 
held on the table (so that the tape measure follows the line of 
the Leg) {A B). From this point on the leg (B) where the two 
feet reaches by the tape measure one measures perpendicularly 
to the table (B C), and the number of inches in the line B C can 
be read as degrees of flexion of the thigh by consulting Table II. 
For instance, if the distance between the point on the leg and the 
table is 12 J inches it represents 31° of flexion deformity of the 
thigh. 

Table II. 1 



0. 5 inches. 


1° 


6. 5 inches. 


16° 


12. 5 inches. 


31° 


18. 5 inches. 


50° 


1.0 " 


2 


7.0 " 


17 


13.0 " 


33 


19.0 " 


52 


1.5 " 


3 


7.5 " 


19 


13.5 " 


34 


19.5 " 


54 


2.0 : ' 


4 


8.0 " 


20 


14.0 " 


36 


20.0 " 


56 


2.5 " 


6 


8.5 " 


21 


14.5 " 


37 


20.5 " 


58 


3.0 '« 


7 


9.0 " 


22 


15.0 " 


39 


21.0 " 


60 


3.5 " 


9 


9.5 " 


24 


15.5 " 


40 


21.5 •' 


63 


4.0 " 


10 


10.0 •' 


2i 


16.0 " 


42 


22.0 " 


67 


4.5 '« 


11 


10.5 " 


27 


16.5 " 


43 


22.5 " 


70 


5.0 '• 


12 


11.0 " 


28 


17.0 " 


45 


23.0 " 


75 


5.5 " 


14 


11.5 " 


29 


17.5 " 


47 


23. 5 " 


80 


6.0 " 


15 


12.0 " 


30 


18.0 ,; 


48 


24.0 " 


90 



" If the leg is so short that it is impracticable to measure off 
twenty-four inches one can measure twelve inches ; ascertain 
from here the distance to the surface on which the patient is 
lying in a perpendicular line in the same way, then doubling this 
distance and looking in the table as before the amount of flexion 
is found." » 

A trophy. The circumference of the thighs, the knees, and 
the calves is then measured at corresponding points to test for 
atrophy or for other irregularities that may require explanation. 
The atrophy of joint disease affects the entire limb, and it is an 
unfailing symptom except in the earliest stage of the disease. It 
might be concealed in the thigh by a deep abscess, but it would 
still appear in the calf. 

Local Signs of Disease. The hip-joint is so concealed by the 
overlying tissues that the local sensitiveness and swelling which 
usually accompany similar disease at the knee and ankle are often 
absent. Firm pressure, before or behind the trochanter, or over 
the head of the femur usually causes some discomfort, however. 
I d many in-tances a peculiar resistance of the deeper parts, caused 
by iu tilt ration of the tissues that cover the joint, is evident on 
palpation ; and swelling about the joint and thigh, caused by 

1 G. L. Kingsley. Boston Medical and Surgical Journal, July 5, 1888. 



TUBERCULOUS DISEASE OF THE HIP-JOIXT. 31 9 

effusion or by deep abscess, is not unusual when patients are first 
brought for treatment. Sensitiveness of the skin and local eleva- 
tion of the temperature may be present if the disease is acute, 
particularly if an abscess is on the point of breaking through the 
skin. 

The diagnosis of tuberculous disease of the hip, except, per- 
haps, in the stage of inception, is in most instances evident 
on a systematic examination, such as has been outlined, and 
it is probable that errors are due rather to a neglect of such 
examination than to any particular obscurity that the ordinary 
case may offer. 

Diagnosis. Local Irritation. Strains of the muscles of the 
thigh, enlarged glands in the groin, irritation or disease of the 
genitals may, in infancy or early childhood, cause persistent 
flexion of the thigh and pain on motion. Simple muscular 
strains quickly recover, while the inflamed glands and other 
causes of local irritation are usually apparent on inspection. 

" Growing Pains." So-called growing pain is probably due in 
many instances to strain of the muscles or to injury about the 
hip ; in other cases it may be explained by rheumatism. 

Local Injury. It would appear that injury, often of a trivial 
character, may cause congestion in the neighborhood of the 
epiphyseal cartilage of the head of the femur and that injury of 
this character in delicate children may be the predisposing cause 
of tuberculous disease. Such a sensitive condition causes a 
limp, pain, or discomfort on overuse and restriction of motion. 
These symptoms may last a few days or a few weeks ; they 
may disappear and recur from time to time, and they can only 
be distinguished from those of incipient disease by continued 
observation. 

Synovitis. In certain cases of injury synovial effusion may be 
present, although this is unusual. 

In the cases in which the functional disturbance is caused by 
local irritation or by slight strain the symptoms are of sudden 
onset and are evidently of trivial importance, but if there is any 
doubt as to the diagnosis the hip should be bandaged and the 
patient should remain in bed or at rest until the complete subsid- 
ence of the symptoms or their persistence make- tin- diagnosis clear. 

Anterior Poliomyelitis. Occasionally anterior poliomyelitis may 
be accompanied by pain on motion in the affected limb before 
paralysis is apparent, but in a few days at most the diagnosi 
evident. 



320 



ORTHOPEDIC SURGERY. 



Rheumatism. Rheumatism is usually of sudden onset. It is 
almost always migratory in character and it is accompanied by 
fever. If it were confined to a single joint, as is sometimes the 
case in young children, and if the history were obscure, the diag- 
nosis might be uncertain for a time. In such cases appropriate 
remedies should, of course, be employed. 

Scurvy. This is also an affection whose symptoms are general 
in character. It is, therefore, more likely to be confounded with 
rheumatism than with a local disease. In rare instances one 
joint only appears to be involved, but this is, as a rule, the knee 
rather than the hip. Pain on motion of the limbs, in an infant 
artificially fed, always suggests scurvy. 

Infectious Arthritis and Epiphysitis. Mild forms of infectious 
arthritis may follow scarlet fever, diphtheria, pneumonia, and, in 
a more severe and destructive form, typhoid fever. As a rule, 
however, several joints are involved, and, although the affection 
might be mistaken for rheumatism, it could hardly be confounded 
with local tuberculous disease. 

Infectious arthritis or epiphysitis of the hip-joint is not un- 
common in early infancy. It is of sudden onset, accompanied by 
high fever and by constitutiona disturbance. These symptoms, 
together with the local heat and swelling, caused by the rapid 
formation of pus, show the character of the affection and indicate 
the necessity for prompt surgical intervention. 

Gonorrheal arthritis is a form of joint infection that in adult 
age may resemble somewhat the subacute form of tuberculous dis- 
ease. As a rule, however, it is of sudden onset and is evidently 
associated with the local disease. 

Extra-articular Disease. Disease in the neighborhood of the 
joint, as of the trochanter or of the tuberosity of the ischium, 
may cause a limp and pain ; in most instances the local sen- 
sitiveness and local swelling indicate the seat of the disease, while 
motion of the joint is limited only in the directions that cause 
tension on the sensitive parts. 

Osteoarthritis of the Hip. Osteoarthritis at the hip-joint may be 
mistaken for tuberculous disease, and at times the diagnosis may be 
obscure. This is, however, a disease of adult life, and it is in most 
instances accompanied by other evidences of a general affection. 
The general form of rheumatoid arthritis in childhood may begin 
in a single joint. The pain may be severe, and there may be 
muscular spasm and distortion of the limb. The diagnosis is 
usually made clear by the successive involvement of other joints. 



TUBERCULOUS DISEASE OF THE HIP-JOIST. 321 

Pott's Disease. Disease of the lumbar region of the spine before 
the stage of deformity, when the pain is referred to the lower 
extremities, and in which unilateral psoas contraction causes 
a limp, is often mistaken for hip disease, although the dis- 
tinction between them is very clear. Psoas contraction limit- 
extension only ; all the other movements of the limb are unre- 
strained. The muscular spasm, of which the psoas contrac- 
tion is a pan, is a spasm of the muscles of the spine about the 
seat of disease, as is evident on examination. Other can- - 
psoas contraction have been mentioned in the consideration of 
Pott's disease. In exceptional cases active disease of the lower 
region of the spine in young children may set up spasm of the 
muscles about the hip, and vice versa, so that it may be impossible 
to decide at the first examination whether the irritation is in the 
hip or in the spine or in both. 

Sacro-iliac Disease. Disease of the sacro-iliac junction is very 
uncommon in childhood. The symptoms and the attitude 
resemble sciatica rather than hip disease. There is local pain at 
the seat of disease upon lateral pressure on the pelvis, and if the 
pelvis be fixed the motion at the hip-joint will be found to be 
free and painless. 

Disease of the Bursae about the Joint. Inflammation of the- 
bursa? about the hip may cause local swelling and sensitiveness, 
a limp and limitation of motion in certain directions, but the 
characteristic muscular spasm of hip disease is absent. Iliopsoas 
bursitis forms a fluctuating swelling in Scarpa's space, gluteal 
bursitis a localized swelling of the buttock. 

Coxa Vara. Depression of the neck of the femur is a simple 
deformity in which disease is absent. It causes a limp and more 
or less discomfort, but the character of the deformity, shown by 
the actual shortening and by the elevation and prominence of 
the trochanter distinguishes it from hip disease, in which these 
are late symptoms. In coxa vara there is unequal limitation of 
motion, abduction, flexion, and inward rotation being somewhat 
restricted, while extension, the first motion limited in hip ib- 
is as a rule not affected. 

Fracture of the Neck of the Femur in Childhood or Traumatic 
Coxa Vara. Fracture of the Deck of the femur in childhood i- 
often of what may be termed the green-stick variety, a depr< 
of the neck of the femur without actual separation of the frag- 
ment ; and in many instances the pati< ible to walk about 
within a ^hort time after the accident In such limp 

21 



322 ORTHOPEDIC SURGER Y. 

and discomfort, attended during the stage of repair by a certain 
degree of muscular spasm, are often mistaken for the symptoms 
of disease. The history of the accident followed by immediate 
disability, the shortening and the elevation of the trochanter 
are usually sufficient to exclude disease. In doubtful cases the 
X-ray may be required to establish the diagnosis. 

Congenital Dislocation of the Hip. Congenital dislocation of 
the hip causes a limp, but it is a limp that has existed since the 
child began to walk and that is unaccompanied by the symptoms 
of disease. The nature of the disability should be apparent on 
examination. 

Hysterical Joint. In hysterical subjects a limp, apparent pain, 
and distortion of the limb, often following slight injury, may 
simulate disease. Hysteria is very uncommon at the period of 
life in which tuberculous disease is most frequent. Patients 
suffering from hysterical joints usually present other symptoms 
of hysteria ; the characteristic signs of disease, muscular spasm 
and atrophy, are absent, while the apparent discomfort and the 
voluntary distortion are quite out of proportion to the physical 
evidences of injury. 

The X-ray in Diagnosis. Roentgen pictures are of far more 
value in demonstrating deformity than in establishing early diag- 
nosis of disease, especially at the hip in early childhood, when so 
large a part of the extremity of the femur is cartilaginous. The 
pictures are of value, however, in showing the destructive effect 
of the disease on the head of the femur or acetabulum, and thus 
giving one a clearer conception of the actual condition of the joint 
than would be possible otherwise (Fig. 192). In older subjects 
it may be possible to demonstrate the presence of disease in the 
interior of the bone by this means, but in any event Roentgen 
pictures are of value only when interpreted by knowledge of the 
physical signs. 

Method of Recording a Case. The record should contain 
the general history of the patient together with an account of the 
more important symptoms, and of the treatment that may have 
been employed. The physical examination should include the 
weight and height for comparison with the normal standard, and 
as a basis on which to judge the future progress of the case. 
Then follows a brief description of the gait and attitude, of the 
character of the distortion, if it be present, and of the changes 
from the normal contour. If restriction of motion is present, 
its causes are stated if possible ; whether, for example, it is due 



TUEEECULOUS DISEASE OF THE HIP-JO I XT. 323 

to simple muscular spasm or in part to adhesions and contrac- 
tions. 

The presence or absence of heat and swelling, of abscesses, 
sinuses, and the like is indicated. If there is actual shortening 
of the limb its causes and distribution should be stated ; whether 
it is the result of simple retardation of growth or of elevation of 
the trochanter, as may be ascertained by Nekton's line and by 
Bryant's triangle. 

If the elevation is due in great part to the enlargement of 
the acetabulum, while the upper extremity of the femur remains 
fairly normal in shape, the projection of the trochanter is 
more noticeable, and the distortion of the limb in adduction is 
greater, than when the elevation is the result of destruction 
of the head of the bone. In this class of cases Roentgen 
pictures are of service in showing the actual condition of the 
joint (Fig. 193). 

A condensed account of the more important points in the 
physical examination may be presented by the formula used at 
the Hospital for Ruptured and Crippled, as follows: R.A. — 
R.U.— R.T.— R.K.— R.C.— A.G.E.— A.G.F.— A.S.P.— L.A. 
_ L.U.— L. T.— L.K.— L.C. 

" A " indicates the distance from the anterior superior spines 
to the internal malleoli. 

" U," from the umbilicus to the same points. 

u -jy* a j£ " anc j u q» £n e circumferences of the limb at the 
thighs, knees, and calves. 

" A.G.E." indicates the angle of greatest extension. 

" A.G.F.," the angle of greatest flexion. Thus the restriction 
of the range of anteroposterior motion at the hip is shown by 
these measurements. 

"A.S.P." is the transverse diameter of the pelvis between the 
anterior superior spines, the measurement required in Lovett's 
table for ascertaining the degree of lateral distortion. 

If, for example, the record read : 

R.A. 18J— E.U. 20 — R.T.ll — R.K. 8]— R.C. 7]— A.G.E. 150— A.8.P. 7 
L.A. 18J— L.U. 21I-L.T.101-L.K. 8',— L.C. 1\— A.G.F. 90 

it would show at a glance that there was no real shortening, 
that the limb was abducted because there is one and a quarter 
inches of apparent lengthening, according to the table, the equiv- 
alent of 10 degrees of abduction. It would -how thai there w&b 

permanent flexion of 30 degree- and a range of motion between 



;*24 



ORTHOPEDIC SURGERY. 



the limits of flexion and extension of 60 degrees, as compared 
with the normal of about 130 degrees. 

The following details of the one thousand cases of hip disease 
investigated for me by Ashley are of interest as illustrating the 
character of the cases treated at the Hospital for Ruptured and 
Crippled : 



The Duration of Disease when Treatment was Begun. 



Three months or less 
Three to six months 
Six months to one year 
One year . 
Two years . 
Three years 



396 
170 



124 



29 



Four years 21 

Five years 17 

From five to ten years . . 35 

From ten to forty years . . 16 

Not stated 37 

1000 



The Degree of Deformity Present on First Examination. 



No deformity . 






130 


55 degrees of flexion 






10 


5 degrees of flexion 




44 


60 " " " . 




26 


10 " " " . 




89 


65 






8 


15 






69 


70 






22 


20 






118 


75 






2 


25 






32 


80 






11 


30 






135 


85 ' 






1 


35 






56 


90 






12 


40 






. 70 


More than 90 . 






1 


45 






41 


Not stated . 






55 


50 






68 












1000 



Restriction of Motion at First Examination. 



Normal motion 30 

A range of motion through 105 degrees 14 

90 65 

75 49 

60 95 

45 67 

30 112 

15 95 

5 " 157 

No motion 147 

Not stated 169 

1000 

Attitude of the Limb at First Examination. 

Flexion to a greater or less degree 814 

No flexion 130 

Not stated 56 

1000 

Other Distortions Recorded. 

Abduction 254 

Adduction 167 

External rotation 166 

Internal " 58 



TUBERCULOUS DISEASE OF THE HIP-JOIXT. 325 



Actual Shortening when Treatment was Begun. 

Y A inch 129 1\{ inches 5 

143 2% " 5 

% ■" 22 2^ " 2 

1 " 51 3 2 

1# inches 9 3# " 2 

1J4 " 16 3i' 2 " 2 

1 - 6 9H " 1 



416 

Shortening absent or not stated in . 584 

Abscess was present in 105 

Treatment. The principles that should govern the treatment 
of a disease are best indicated by the study of cases that have 
received no treatment, and that show, therefore, the natural his- 
tory of the affection. 

A characteristic case of tuberculous disease of the hip-joint 
begins insidiously. It causes a slight limp and at times discom- 
fort and pain. In the early stage of the disease there is slight 
flexion of the limb, usually combined with abduction, the instinc- 
tive assumption of the attitude of rest. As the disease progresses 
the limb becomes less capable of performing its proper function ; 
the range of painless motion becomes more and more restricted, 
and the attitude changes to one of increased flexion and adduction, 
the attitude in which the limb is best protected from injury and 
in which it is least capable of performing its share of normal 
work. Pain is more constant, abscess is often present, and the 
constitutional effects of a depressing disease may be apparent. 
This progression of symptoms and attitudes is so fairly constant 
that hip disease was in former times often divided into stages corre- 
sponding to these early and later manifestations of its effects. AVhen 
the limb has reached the position of greatest protection, when mo- 
tion which at first was limited only by the involuntary spasm of 
the muscles that are now atrophied, is restricted by adhesions and 
contractions, pain often ceases to be a troublesome symptom, the 
general health improves, and effective repair begins. During 
the progressive stage erosion of the opposing surfaces of the joint 
has advanced, always more rapidly at the points of mutual 
pressure and frir-tion, the upper and inner surface of the head of 
the femur and the upper margin of the acetabulum, and here the 
-•• remains active while repair progresses at the points which 
have been relieved from irritation. Thus in many instances the 
upper margin of the acetabulum is destroyed and a subluxation 
of the femur takes place (Fig. 181), a displacement favored by 



; (26 OR THOPEDIC S URGER Y. 

the attitude of flexion and adduction, and induced by muscular 
spasm and by pressure upon the limb. In some instances there 
is complete displacement, and when the diseased parts are thus 
separated from one another by this form of pathological dislo- 
cation relief of symptoms and practical recovery may quickly 
follow, although sinuses leading to areas of local disease or to 
fragments of necrosed bone may persist for many years. 

Nature's cure of hip disease implies recovery with a shortened 
and distorted limb, a final result which is common enough even 
when treatment has been employed to explain the popular con- 
ception of what hip disease entails (Fig. 190). 

As has been stated, it was customary in former years, when 
treatment was neglected or less efficient than at the present time, 
to speak of a first, second, and third stage of hip disease, corre- 
sponding to the character of the deformity, but early or later 
stage as used by the writer refers to the inception and progression 
of the local pathological process, not to the distortion of the limb. 

There are many cases of hip disease in which the primary focus 
in the head of the bone is so limited in extent that perfect func- 
tional cure may result under any form of treatment, or non-treat- 
ment even. And there are others in which the disease is of such 
a destructive character that the result must be disastrous in spite 
of treatment. But there can be no doubt that by. early diagnosis 
and by efficient protection a vast amount of suffering may be 
prevented, that useful function may be preserved, which would 
otherwise have been lost. 

The object of treatment is to prevent the symptoms and the 
effects of the disease that have been outlined as characteristic of 
the untreated cases. To relieve the pain that depresses the 
vitality of the patient. To relieve the muscular spasm that 
induces distortion of the limb, and that stimulates the activity 
of the destructive process by increasing the pressure and friction 
of the diseased surfaces of the opposing bones. To correct and 
to prevent deformity and to prevent, as far as may be by lessen- 
ing the pressure and by restraining motion, the upward displace- 
ment of the femur that causes irremediable distortion. 

There are cases in which radical removal of the diseased parts 
may be indicated, and there are times when acute symptoms may 
require absolute rest of the patient. But in the management of 
a chronic tuberculous disease, throughout the period of years that 
may elapse before cure is accomplished, the primary require- 
ments of the treatment that have been indicated must be met, as 



TUBERCULOUS DISEASE OF THE HIP-JOINT. :V2: 

far as may be, by appliances that allow exercise in the open 
air. 

Mechanical Treatment. The most effective treatment of a dis- 
eased joint is that which assures it the most perfect rest and pro- 
tection. If the disease is in the earliest stage and confined to 
the interior of the bone, rest offers the most favorable condition 
for repair and for preservation of the joint. If the disease is 
further advanced, complete relief of function affords an oppor- 
tunity for nature to check its progress and to preserve, it may 
be, a part of the joint from invasion. If the joint is already 
involved, rest offers the best opportunity for repair by preventing 
friction that stimulates the progress of the disease and increases 
its destructive effects. Whatever checks or retards the progress 
of the disease correspondingly relieves its symptoms and prevents 
constitutional depression and thus preserves the vital resist- 
ance, both local and general, upon which the cure of the disease 
ultimately depends. Rest of a diseased joint of the lower ex- 
tremity necessitates splinting, stilting, and traction. 

Splinting naturally signifies the fixation that may be attained 
by the application of a splint, extending a sufficient distance on 
either side of the part to be fixed. 

Stilting — the elevation of the foot from the ground so that 
jar and pressure on the diseased articulation may be removed. 

Traction — a sufficient force exerted upon the limb to over- 
come and to control the spasmodic action of the muscles. 

The knee-joint, the junction of two levers of similar size and 
function, may be easily controlled or placed at rest by means of 
apparatus. But the hip-joint is a ball-and-socket joint which 
allows free motion in many directions, and, being the junction of 
the body and the limb, two segments of different size and func- 
tion, it is especially difficult to control. For this reason as 
much as any other, perhaps, the treatment of hip disease has 
been the subject of controversy for many years. And even al 
the present time one can hardly describe the treatment of hip 
disease adequately without contrasting the methods of treatment 
that are in common use. 

Bach an exposition should begin naturally with a description 
of what has long been known as the American treatment, in 
which traction has always occupied the most important place. 

The Traction Hip Splint. The traction hip Splint consists of a 
pelvic band and an upright. The pelvic band is made of aheel 
steel about an eighth of an inch in thickness and one and one- 



328 



ORTHOPEDIC SURGERY. 



eighth inches in width, sufficiently strong to support the weight 
of the body without yielding, bent into a U-shape to conform to 
the pelvis, but wide enough to cause no anteroposterior pressure. 
As Taylor puts it, there should be room enough for the pelvis to 
move freely in it. This band embraces about three-quarters of 
the pelvis at a point just above the trochanter. It is covered 
with leather, and is provided with a strap to complete the cir- 
cumference. Upon the pelvic band four buckles are placed for 
the attachment of the perineal bands. The two buckles on the 



Fig. 195. 



Fig. 196. 



Fig. 197. 







The traction hip splint, with overlapping upright and windlass, used at the Boston 
Children's Hospital. (Bradford and Lovett.) 

front band are placed directly above the attachments of the 
adductor muscles, on either side of the genitals. Behind, the 
buckles are placed much farther apart, somewhat to the outer 
side of each ischial tuberosity, upon which, in great part, the 
weight of the body is to be supported. The pelvic band is 
bolted firmly to the upright at a slight inclination, correspond- 
ing to the inclination of the pelvis. The upright extends from 
the top of the trochanter to two or more inches below the sole of 
the foot. It may be made in one piece or in two sections over- 



TUBEBCULOUS DISEASE OF THE HIP-JOIST. 329 

lapped and attached to one another by screws, to allow for 
adjustment (Fig. 196). It is turned inward at a right angle 
below the foot and is shod with leather or rubber. The foot- 
piece may be provided with a windlass (Fig. 195), or the traction 
may be made by simple straps attached on either side (Fig. 201). 
At about the middle of the upright is placed a support of light 
steel, which is provided with a broad leather strap for the pur- 
pose of fixing the thigh to the brace and supporting the knee. In 
some braces a second similar support is placed at the upper part 
of the stem ; in others the knee is supported only by a broad 
leather pad which covers its inner surface and is attached to a 
cross-piece on the upright by straps, as in the Taylor brace. In 
the Taylor brace, which has served as a model for all similar 
appliances, the upright is a steel tube into which slides a rod, 
supporting the foot part of the brace, the two parts being joined 
with a rack-and-pinion attachment and lock, so that the brace 
may be lengthened or shortened by means of a key (Fig. 200). 

Traction Straps. Traction upon the limb is made by adhesive 
plaster, preferably that known as moleskin (yellow) plaster, which 
is far less irritating to the skin than rubber plaster. 

These plasters should be cut into a shape corresponding to the 
lateral aspect of the thigh and leg, thus : wide above and narrow 
below, reaching from the trochanter on the outer, and from the 
pubes on the inner side, to the malleoli (Fig. 221). The lower 
ends are reinforced by a second layer of plaster and to them 
buckles are attached. The plasters are then applied to the limb 
and are held in place by a bandage which is smoothly applied 
and then sewed, to prevent disarrangement. The object of the 
bandage is primarily to assure the adhesion of the plaster and 
secondarily to keep it clean. It can be replaced by a properly 
fitted covering of stockinette or by a stocking leg. 

Another method of applying the plaster, designed to obtain 
a better hold upon the limb, is that devise 1 by Taylor, and 
described by him as follows: " The first important object is to 
seize the leg in such a manner as to exert against it an unyield- 
ing force. This should be done in such a manner as will QOl 
interfere with the circulation, nor injure the knee, by unequal 
-train either below or above it. Tn other words, the whole leg 
should be grasped in such a manner that the knee will 1"' 
supported. It maybe don*- as follow-; A strip of adhesive 
plaster, Long enough to reach from the waisl to the foot, and 
from three to five inches wide at the upper and about one-third 



330 



(HI T HOPE DIC S URGER Y. 



that width at the lower end, is taken and cut into five tails, as 
shown id the accompanying illustration (Fig. 198). A piece 
from four to six inches long is cut from the centre tail and added 
to the lower end to strengthen it ; and, if the patient be strong, 
one or two more pieces are laid on the same place, where a buckle 
is attached. Two similar straps are prepared, one for the inside 
and one for the outside of the leg, and laid against the lateral 



Fig. 



Fig. 199. 





C. F. Taylor's method of applying adhesive plaster. 



aspects of the leg, the ends with the buckles beginning about two 
inches above the internal and external malleoli, and the centre 
tails reaching the entire length of the leg and thigh, to the peri- 
ixiim inside and the trochanter on the outside. The lower strips 
or tails are then wound spirally around the leg to the pelvis and 
afterward the other two pairs of tails, which are cut down to just 
above the knee, are also wound about the thigh in the same 
manner. When completed the thigh is involved in a network of 



TUBEJRCULOUS DISEASE OF THE HIP-Jo/XT. 



331 



Fig. 200. 



strips of adhesive plaster, which act equally and without pressure 
ou the whole surface. The leg has about one-fourth of the 
attachments, and the thigh three-fourths, which is found to be the 
right proportion to protect the knee equally from compression or 
strain. A few turns of the roller bandage are then made around 
the ankle just under the lower ends of the straps, which serves 
as a protection to the flesh under the 
buckles, and then it is continued over 
the straps ou the whole leg. Thus 
prepared, the patient is ready for the 
splint" (Fig. 199). 

At the Boston Children's Hospital 
the lower ends of the adhesive straps 
terminate in tapes that extend be- 
low the foot for attachment to the 
windlass, which is used with the 
cheaper form of brace. 

Perineal Bands. Perineal bands 
are made by covering a firm, wide, 
unyielding band of webbing with 
several folds of blanket or similar 
material and then binding it smoothly 
with canton flannel. These are 
made in different lengths and sizes, 
as may be required. 

The "High Shoe." The best and 
lightest material for raising the shoe 
worn on the sound foot to corre- 
spond with the brace is cork, and 
the ordinary thickness is two and 2KS^ t 32^i5 p i!!SS 

vided with an abduction screw and 

a half inches. A good and cheap a strap to regulate the inclination of 

. _ the pelvic baud on the upright. 

substitute may be made or light 

wood provided with a leather sole, and in certain cases a patten 

of metal may be used. 

The Application of the Traction Hip Splint. The traction brace 
is applied in the following manner : 

The patient lying upon his back, tie- pelvic band La first 
adjusted and is strapped about the body. The perineal supports 
are then drawn firmly into place so that pressure ou the upright 
does not move the pelvic band from its proper position just 
above the trochanter. The brace is then pushed upward against 
the resistance of the perineal bands, while the limb is at the same 




332 



ORTHOPEDIC SURGERY. 



time drawn downward and is fixed by attaching the straps to the 
buckles at the ends of the adhesive plasters. If the brace is 
provided with a windlass or ratchet, further traction is applied 
to the point of tolerance by means of the key, care being taken 
in adjusting the brace that it does not project so far below the 
foot as to more than equal the extra length provided by the high 



Fig. 201. 



C 






& 



The Judson brace. 



This has but one perineal band, and the upright is bolted firmly to 
the pelvic band. 



shoe on the sound side. The knee band is then adjusted and in 
many instances a strap is placed about the ankle and the brace 
to assure greater security. The shoe is then put on, the leg 
clothing is drawn over the brace, and the patient is allowed to 
stand. If in walking the patient is inclined to tilt the foot down- 
ward and to bear the weight on the toe, a strap is attached to the 
middle of the foot-piece and fastened to a buckle on the heel of 



TUBERCULOUS DISEASE OF THE HIP-JOIST. 333 

the shoe with sufficient tension to hold the foot in the horizontal 
position. 

By means of this brace the weight is borne entirely upon the 
perineal bands ; thus the joint is relieved from pressure and from 
jar. The perineal bands should be accurately adjusted to pass 
upward in front, parallel to one another on either side of the 
genitals, in order to avoid pressure on the inner borders of the 
thighs ; while behind they turn diagonally outward in order to 
pass over the tuberosities, which are best adapted for weight 
bearing. 

In the original Taylor hip brace the pelvic band is bolted to 
the upright in a manner to allow anteroposterior motion, and the 
inclination of the pelvic band is regulated by a strap attached 
to the upright for better adjustment (Fig. 200), when the limb 

Fig. 202. 




The reduction of flexion by means of the traction hip splint. (C. F. Taylor.) 

is flexed to a marked degree. This brace has been modified by 
Taylor by shortening and changing the shape of the pelvic band 
for the use of but one perineal support (Fig. 231) ; and a similar 
form of brace is used by Judson. The shortened pelvic band 
lessens the restraint of the brace upon the motion of the limb, 
and seems to offer little compensating advantage. 

Before the traction brace is used in ambulatory treatment, dis- 
tortion of the limb, if it be present, should be reduced ; or if tie- 
disease be particularly acute preliminary rest in bed until tie- 
subsidence of the symptoms is advisable. 

The Reduction of Deformity by Means of the Traction Brace. 
The patient lies in bed upon a firm mattress; tie- distorted limb 
is then raised to slightly more than a sufficient angle to relax the 
contracted muscles and to straighten tie- Lumbar lordosis ; it ia 
then abducted or adducted if necessary until tie- level of tie- 



334 ORTHOPEDIC SURGERY. 

pelvis is restored. The pelvic band is made to conform to this 
greater relative inclination of the pelvis by lengthening the pos- 
terior strap ; the brace is then applied, the limb being held in 
the attitude of deformity by a sling or support (Fig. 202), and 
as much traction as the patient can tolerate is exerted by length- 
ening the upright. The direct traction exerted by the brace may 
be reinforced by means of a cord running over a pulley at the 
foot of the bed, in the line of the brace, to which a weight of ten 
or more pounds (Fig. 203) is attached. Thus the pressure of 
the perineal bands is somewhat lessened. Efficient traction will 
quickly reduce recent deformity caused by muscular contraction, 
and as this is lessened the position of the limb is correspondingly 
changed until it lies extended and parallel with its fellow. If 
adduction be combined with flexion the perineal band on the 
side opposite to the disease is tightened from time to time, or a 
direct push against the opposite adductor region is exerted by 
means of a bar attached to the brace opposite the knee (Fig. 
227). In ordinary cases the deformity may be reduced by this 
means in from two to six weeks. 

The brace should be worn day and night. The perineal bands 
may be loosened at times to allow for bathing the skin with 
alcohol and for powdering, in order that the skin may be kept 
dry ; but at such times, if the disease be acute, manual traction 
should be made until the brace has been readjusted. The adhe- 
sive plasters, if of moleskin, may often remain in position for 
three months or longer. When they are removed the limb is 
gently bathed with alcohol. Excoriations are unusual unless 
rubber plaster is used. If the skin is abraded the part should be 
powdered with boracic acid and protected from the plaster by a 
layer of gauze. 

The Relative Efficiency of the Traction Hip Splint. 
In analyzing the action of this brace it is evident at once that it 
is thoroughly effective as a stilt. It is effective as a traction 
appliance, in the sense of relieving muscular tension, in direct 
proportion to the care that is exercised in its adjustment. Trac- 
tion by this appliance may be made constant and effective, even 
to the point of practical fixation while the patient is in bed, or 
when crutches are used, in ambulatory treatment. But when the 
apparatus is used as a walking brace, as was designed by its 
inventor, constant traction is not exerted, for the traction straps 
alternately relax and tighten when the weight of the body falls 
upon and leaves the brace in walking. When the brace is off 



TUBEECULOUS DISEASE OF THE HIP-JOINT. 



335 



the ground the joint is subjected to the traction that the brace 
exerts, plus its weight, as contrasted with cessation of traction 
and the relief from the weight when the brace supports the body 
at the alternate step. Thus the critics of the brace assert, in 
somewhat exaggerated language, that it exercises a pumping 
action on the joint. As a matter of fact, the observation of 
patients under treatment by this method will show that little 
actual traction is exerted in the ordinary cases ; that the so-called 
traction really serves principally for the adjustment of the brace, 
which by its weight exercises a certain intermittent traction dur- 
ing locomotion. The hold of the encircling band upon the pelvis 
assures a considerable restriction of motion, but whatever splint- 
ing action it may have depends upon the degree of traction, 
which is never effective enough, however, to prevent a certain 



Fig. 203. 




A method of reducing flexion in hip disease. The brace is adjusted to the angle of 
deformity, and in addition to the direct traction of the apparatus weights are attached to 
the brace* itself. In the illustration counter-traction, by means of perineal bands attached 
to the head of the bed, is shown. 

amount of motion. This point is illustrated by the experiments 
of Lovett, 1 which are described by him as follows : 

"In these experiments a long traction splint was fitted with a 
self-registering pencil by means of which motion at the hip-joint 
was recorded upon the skin over the ilium. This was done 
simply by carrying the shaft up so that it held the pencil perpen- 
dicularly to the skin. A splint fitted with thia r was 
applied to a boy with normal hip-joints, and traction was made 
up to tli'- usual point, being about three pounds and a half, as 
registered by a spring balance inserted in the extension straps. 
With this splint on the boy was allowed to walk, and it \\;i- 
found that the hip described an are of thirty-five degrees of joint 



K. w. Lovett. New York Medical Journal, 



336 ORTHOPEDIC SURGERY. 

motion. In sitting down and rising an arc of similar extent was 
described. In another case with normal hip-joints the motion 
was found greater, and the register showed a motion of forty- 
degrees. With a very severe amount of traction — so much so 
that it was almost unendurable — motion of fifteen degrees was 
recorded. This apparatus was first tested by being applied to a 
patient with anchylosis of the hip, when it was found that no 
motion was recorded, the register marking by a dot. These 
experiments certainly seem to show that to a healthy hip-joint 
the long traction splint affords very imperfect fixation, and it 
may be inferred that to a diseased joint equally poor support is 
afforded." 

The fact must be borne in mind that the traction hip splint 
was not intended to be a fixation or splinting appliance. On the 
contrary, Davis, its inventor ; Taylor, who changed it into a 
practicable form, and Say re, who further modified it, each 
believed that motion, except when the joint was fixed by mus- 
cular spasm, was desirable. 

" The first splint, as well as all my modifications, admits of 
free motion of the diseased joint, but rigidly excludes all friction 
of the diseased surfaces upon one another." 1 (Davis.) 

" Motion without friction is not only not injurious, but it is 
highly beneficial." 2 (Taylor.) 

" For the ligaments around a joint will become fibrocartilag- 
inous or even osseous, if motion is denied them, particularly if a 
chronic inflammation is going on within the joint with which 
they are connected. 

" As Dr. Davis is, I believe, the first person who constructed 
an instrument embracing these important advantages, extension 
with motion, I have given him full credit for the same," etc. 3 
(Sayre.) 

Motion without friction in this sense would seem to imply the 
actual separation of the femur from the acetabulum, or distrac- 
tion as distinct from traction. 

That actual distraction is possible at the hip-joint both in 
health and disease is proved by the experiments of Brackett 4 and 
by those of Bradford and Lovett. These experiments show that 
a traction force from ten to twenty pounds is required to cause 

1 Davis. Conservative Surgery, 1867, p. 214. 

2 Taylor. The Mechanical Treatment of Disease of the Hip-joint, 1873, p. 15. 
-,iyre. Lectures on Orthopedic Surgery, 1879, p. 260. 

* Brackett. Transactions American Orthopedic Association, vol. ii. Bradford and Lovett, 
New York Medical Journal, August 4, 1894. 



TUB EH C I ~L I TS DISL\ i SE OE THE HIP- J IS T. 337 

one-eighth to one-quarter of an inch of actual lengthening of the 
limb, even in childhood. It is, therefore, to say the least, 
unlikely that the feeble and intermittent traction exerted by a 
hip splint, when used as an ambulatory support, can be sufficient 
to separate the bones from one another and thus to allow motion 
without friction as was originally claimed for this apparatus. In 
fact, it would appear that the claim that motion was of positive 
benefit to the diseased joint was afterward modified by the up- 
holders of this method of treatment to a negative assertion of its 
harmlessness, for example : 

" If the disease permits a certain amount of motion at the 
affected articulation, motion within the limits set by nature is 
not harmful." 1 (Shaffer.) 

This statement would seem to imply that the motion per- 
mitted by the apparatus might be varied in accordance with the 
degree of restriction that a particular case presented, provided that 
this motion were restricted to the limit set by nature. In actual 
practice, however, the same form of brace is applied, and with 
the same adjustment, in every case ; or as it is stated in a paper on 
the final results of the mechanical treatment by this apparatus in 
dispensary practice, under Shaffer's direction : "In each case 
reported a Taylor traction splint was applied soon after the first 
examination. . . . The patient, unless recumbency was 
necessary to overcome a malposition of the limb or unless the 
symptoms were so acute as to demand rest, was allowed almost 
unlimited exercise in the open air." 2 Yet it may be inferred 
from the report of the final results in these cases that in spite of 
the protection, which, in many instances, must have restricted 
motion within the limits present at the first examination, the 
range of motion became more and more restricted, for in 1<> of 35 
cases reported anchylosis resulted, and in 7 others the motion was 
less than ten degrees. Thus in 74 per cent, of the cases practical 
fixation of the joint was found on the final examination. 

In criticising these statistics it must be borne in mind that the 
patients were treated under all the disadvantages of dispensary 

practice, and that the final usefulness of a limb i- by n <;m- 

in proportion to the freedom of motion that may be preserved ; 
-till with these reservations it can hardly be claimed that the 
proportion of absolute or partial anchylosis would have been 

Shaffer. Transactions American Orthopedic Association, vol. 11 p. 
- iflterand Lorett On the Ultimate Results of the Mechanlca 
Dfseai rk Medical Journal, May 21, M 

22 



338 OR THOPEDIC SURGER Y. 

greater than this had any other system of treatment been em- 
ployed. 

At the present time the theory that motion of a diseased joint 
is of benefit, or even that it is harmless, has few supporters even 
among those who use the traction brace exclusively. On the 
contrary, the motion that cannot be prevented is excused because 
of the practical efficiency of the brace and because it is believed 
that no more effective protection can be attained by any other 
method of ambulatory treatment. 

In all acute cases a period of rest in bed with traction to the 
point of actual distraction is advised. When ambulation is 
resumed the braced limb is made pendent by means of the high 
shoe aud crutches, so that uninterrupted traction may still be 
exerted, and the brace is only used as a supporting appliance 
when the symptoms indicate that the disease is quiescent. 

Although this modification of treatment was not followed by 
Taylor, still in his later writings he states that motion is of 
advantage only in the stage of recovery. And it is evident that 
his success was due to the extreme care which he exercised in the 
supervision of the patients, and in adapting treatment to the vary- 
ing phases of the disease rather than to any theory that he may 
have advocated. 1 

As has been stated, treatment by the long traction brace, by 
means of which motion without friction was at one time claimed 
to be possible, and in which traction is the distinctive feature, is 
sometimes called " The American Treatment of Hip Disease." 
In this sense the direct splinting of the joint without traction, by 
means of the Thomas brace, might be called in distinction " The 
English Treatment." 

The Thomas Treatment of Hip Disease. H. O. Thomas, 2 of 
Liverpool, writing at a time when in America it was generally 
believed that motion was essential to the well-being of a diseased 
joint, and when fixation was supposed to predispose to, or to 
actually induce, anchylosis, states "that continuity of extension 
per 8€ is not a remedy in hip-joint disease ; in its application it 
involves unavoidably a fractional degree of fixation which is suffi- 
cient to mask the evil of this ridiculous malpractice." 

The conclusions on which his treatment is founded are these : 
" The main obstacle to the cure of an inflamed joint is the friction 

1 Boston Medical and Surgical Journal, March 6, 1879. 

uses of the Hip, Knee, and Ankle- Joints, Treated by a New and Effective Method, 
187."), p. 10. 



TUBERCULOUS DISEASE OF THE HIP-JOIST. 339 

and pressure of its surfaces ; consequently the attainment of rest, 
that is of immobility of the articulation, ought to be the principle 
which should guide the treatment. Pressure and concussion are 
less to be feared than friction. Effectual rest csn only be ob- 
tained by mechanical treatment, and for this purpose the appli- 
ances which I here recommend are effectual. The more an 
inflamed joint is moved the stiffer does it become ; while the 
more effectually it is fixed, the sooner and the more completely 
is its capability of movement restored. To insure permanency of 
cure the control should be maintained for a period beyond the 
time when resolution has token place. This prolonged arrest of 



Fig. 204. FrG. 205. 



a 



ZUC^ 



The Thomas hip splint, covered and fitted with shoulder straps. 
(Ridlon and Jones.) 

a joint's movements, for even an unnecessarily 
long period, I have never found to do harm." 

The splint used by Mr. Thomas to cany out 
these principles effectively is described by him 
I La substantially as follows : 

A flat piece of malleable iron, three-quarters 

The splint in its sim- „ ., ., ,. .. ^i £ ■ 1 

piest form, not yet pad- of an inch wide and three-sixteenths of an men 
ded^or covered. (Rid- t hi c k for children, and one inch by one-quarter 
inch for adults, long enough to extend from the 
lower angle of the scapula to the middle of the calf, forms the 
upright. This is fitted to the body of the patient, passing from 
the lower angle of the scapula, in a perpendicular line, down- 
ward, over the lumbar region, across the pelvis, slightly external, 

but close to the posterior spinous pr< of the ilium and the 

prominence of the buttock, along the course of the sciatic Derve 
to a point slightly external to the calf of the leg. I' must be 
carefully modelled to this track. The Lumbar portion of the 



3 10 ORTHOPEDIC SURGER Y. 

upright must be invariably almost a plane surface, but it must 
be twisted slightly on its long axis at the junction of the upper 
and middle third, so that the anterior surface of the lower part 
may look slightly outward to correspond to the contour of the 
buttock and thigh. A second and double bend is made in the 
upright at the point where it passes the buttock, so that the 
thigh part lies on a slightly higher plane than the body part, but 
parallel with it. The upright is then provided with chest, thigh, 
and leg bands (Fig. 204). 

The chest band is of hoop iron one and a half inches in width 
by one-eighth of an inch in thickness. This is bent into an oval 
to correspond with the shape of the chest, being four inches less 
than the circumference at this point if the patient is an adult, 
and of a corresponding size for a child. It is riveted to the 
upper extremity of the brace, so that one-third of its length shall 
be on the side corresponding to the diseased joint and two- 
thirds on the other. The thigh band and leg band are of 
similar material, three-quarters by one-eighth of an inch in 
size. The thigh band, in length equal to two-thirds of the 
circumference of the thigh, is fastened to the upright at a 
point one to two inches below the buttock, and the calf band, 
equal in length to half the circumference of the leg at the calf, 
is riveted to the lower extremity of the brace. Both the thigh 
and leg bands are attached to the brace at points slightly to the 
inner side of the centre, so that the outer arm of each band is 
somewhat longer than the inner. The brace is padded with thin 
boiler felt and is covered smoothly with basil leather. In fitting 
the brace to the patient the long part of the chest band should be 
made to hug the body closely, while the short arm should be 
somewhat away from it. The anterior surface of the thigh part 
of the upright should have a perceptible outward twist and 
should be somewhat on the inner side of the popliteal space. 
Thus the instrument is prevented from rotating outward and 
becoming a side splint. The chest band is closed with a strap 
and buckle ; it is suspended by shoulder straps, and the leg between 
the two bands is attached to the brace by means of a flannel 
bandage. Ridlon states that in practice this bandage is usually 
replaced by a strip of basil leather passed across the front of the 
limb close down to the upper border of the patella, thence back- 
ward and downward to the stem of the splint and pinned to the 
covering, so that the resistance to the downward working of the 
brace is borne by the quadriceps femoris muscle. The ordinary 



TUBEECULOUS DISEASE OF THE HIP- JO EXT. 



:U1 



shoulder straps may be replaced by a single bandage looped about 
the upper part of the stem (Fig. 206). This bandage is twisted 
for a length of about six inches, then separated, the ends being 
carried over the shoulders, are passed through holes in the corre- 
sponding ends of the chest band, where they are knotted, and 
finally the two ends are tied to one another, completing the cir- 
cumference of the chest band. 

This brace is fitted by the surgeon directly to the patient's 
body as he stands erect. If the limb be already flexed the foot 
is raised by blocks until the lumbar lordosis is straightened ; the 



Fig. 206. 




Method of changing the line of pressure on the skin from the Thomas hip splint by 
drawing the tissues to one side. (Ridlon and Jones.) 



brace is then bent to fit the angle of deformity and is applied in 
the usual manner. 

The brace is made of iron because it Is less elastic than Bteel, 
and because it can be more easily twisted by wrenches. It must 
be heavy and strong in order to splint the pari effectively, and 
it can only be an effective splint when it is fixed in it- proper 
position and exercises direct pressure upon the hip-joint. Ln 
cases in which the brace has been properly employed a deep fur- 
should appear in the buttock directly over the Deck of the 
femur. ( mce fitted to the patient it is changed only at infrequent 



342 



ORTHOPEDIC SURGERY. 






intervals and always by the surgeon, who is particularly careful 
not to move the limb during the active stage of the disease. 

The double Thomas hip splint is made by joining two single 
splints. These are riveted to the chest band above and are con- 
nected at the lower ends by a crossbar, unless the brace is to be 
used in the reduction of deformity. Care must be taken that 

the uprights pass to the outer 

Fig 207 . . 

side and not directly over the 
posterior superior spines of the 
ilium. 

The Reduction of Deformity by 
the Thomas Method. Preferably 
in the treatment of children the 
double brace is applied, the sound 
limb being fixed in the extended 
position while the flexed limb is 
supported by the other arm of 
the brace, bent to the angle of 
deformity. The patient is con- 
fined to the bed and, as the mus- 
cular spasm relaxes under the 
influence of enforced rest, the 
brace is straightened slightly by 
wrenches from time to time, at a 
point opposite the joint, to con- 
form to the improved position 
until symmetry is restored. In 
resistant cases this gradual re- 
laxation is hastened by straight- 
ening the brace somewhat at in- 
tervals, to which the attached 
limb must conform — a gradual forcible reduction of deformity. 
According to Ridlon and Jones, the flexed limb is often forced 
to conform to the straight brace by a temporary exaggeration of 
the lumbar lordosis, which lessens as the spasm subsides under 
treatment. 

The treatment is divided by Mr. Thomas into stages : 

1. A preliminary stage of rest in bed for the reduction of 
deformity and to allow for subsidence of acute symptoms. 

2. The patient is then allowed to go about on crutches wearing 
an iron patted at least four inches in height under the sound foot 
(Fig. 207). 




Thomas splint applied with patten and 
crutches. 



TUBERCULOUS DISEASE OF THE HIP-JO I XT. 



343 



3. When all symptoms of disease have subsided and when 
atrophy of the muscles is marked the brace may be removed at 
night. 

4. The brace is finally discarded, but the patten and crutches 
are still used in walking. 

According to Kidlon 1 the records of Mr. Thomas show the 
average time of confinement to the bed to be twenty-two weeks, 
and the average duration of treatment twenty-one months. 

It is stated by Ridlon 2 that in actual practice these principles 
were not carried out, for nearly all the children treated under 
Thomas' direction at the time his observations were made wen 1 
walking about without the high patten and crutches, even before 
the deformity had been overcome and while muscular spasm and 
pain persisted. 



Fig. 208. 




A form of Thomas brace employed in the treatment of infants. The pelvic band assures 
better fixation. The screws at the lower extremity are arranged to permit the addition oi a 
foot-piece for traction. 

This was, however, probably an exigency of practice among 
the poor, and at all events it is in line with Thomas' contention 
that pressure and concussions are less harmful than friction. 

Modifications of the Thomas Brace. Although not so stated in 
his book, Thomas used at times a short brace extending only to 
the lower part of the thigh, thus permitting motion at the knee. 
This was apparently designed as a convalescent splint, although 
it- use was not restricted to that class of cases. In certain cases 
a -trip of iron, " the nurse," was screwed to the Lower extremity 
of the long brace, prolonging it beyond the foot in order 1<» pre- 
vent the patient from bearing weight upon the limb. 

The Thomas brace, so effective in preventing and overcoming 
flexion deformity, does not prevent lateral distortion. In fact, 



1 Transactions American Orthopedic Association, vol. i. p. 17. 
- A Report of Sixty-two Cases of Hip Disease Observed in the PTftCl 
Thomas. New York Medical Journal, October 1 



3 l \ 



ORTHOPEDIC smcERY. 



in twenty-four of the fifty-eight patients examined by Ridlon, 1 
adduction was present ; a larger proportion, it would appear, 
than would be found in a like number of cases under treatment 
with the traction brace. This tendency to lateral distortion may 
be guarded against by placing a half band of material similar to 

Fig. 209. 




The long plaster spiea bandage. The dotted line indicates the position of the steel support. 

the chest band about the side of the pelvis; on the same side 
for adduction, on the opposite side for abduction of the limb. 

The Thomas brace has a great advantage over other appliances 
in it- simplicity. It can be made by a blacksmith, but it must 



Loc. cit. 



TUBERCULOUS DISEASE OF THE HIP-JOINT. ;\\:, 

be fitted by the surgeon. This fitting requires great care. In 
the words of Mr. Thomas, " the fitting, although sometimes 
successful in one visit, may at other times occupy many days. 
The surgeon should mould, by reducing or increasing the various 
curves, until the instrument ceases to tend to rotate, and at none 
of its angles irritates the patient." He concludes in a general 
answer to the criticisms that have always been made on the 
difficulty of adjustment of the appliance as follows : " What I 
can invariably do must be possible to others." 

Treatment by the Plaster Bandage. A third method of treat- 
ment is that by means of the plaster bandage without crutches or 
high shoe. This is simple splinting with whatever protection 
from concussion the support may assure. 

This treatment might be called the German method if the 
traction hip splint and the Thomas brace are to be designated as 
American and English. 

As used in the surgical clinic at Berlin, the plaster bandage is 
applied from the line of the nipples to include the foot, the limb 
being fixed in an attitude of slight flexion, abduction, and out- 
ward rotation. As a rule, the first bandage is applied under 
anaesthesia for the purpose of relaxing the muscular contraction 
and facilitating the application. If nutritive shortening of the 
muscles is present, sufficient force is employed to overcome the 
deformity. The spica is renewed at intervals of from two to four 
months. AVhen the disease is cured and after the bandage is 
finally removed traction at night is employed for a time by means 
of a weight attached to the foot to prevent the tendency to dis- 
tortion. In ambulatory treatment this method has little to 
recommend it except expediency, but as a temporary support to 
be used before the application of a suitable brace the plaster spica 
is most useful. 

When properly applied it is an admirable support, often far more 
comfortable to the patient than any brace, and it is at times an 
indispensable form of dressing. It has the same defects as the 
plaster jacket, and it may receive the same defence that its most 
severe critics have had the least experience in if- use. 

Application of the Plaster Sph \ Bandage. A plaster 
bandage to assure support should tit perfectly, consequently it 
should be applied as closely as is possible. If it ie available th< 
trunk and the limb should be protected by a close-fitting covering 
of shirting, such as is used in the application of the plaster 
jacket. Those parts that are likely to be subjected to pr< 



;UG 



ORTHOPEDIC SURGERY. 



—the toes, the heel, the malleoli, the condyles of the femur, the 
sides of the pelvis, the anterior superior spines, and the thorax — 
should be suitably protected by cotton wadding, which may be 
held in place by a snugly applied canton-flannel bandage. The 
plaster bandage should cover the lower half of the thorax, and it 
should extend to the ends of the toes. It should be applied 
under slight extension very carefully around the adductor region 
and the buttock, which should be entirely covered and supported. 
At this point, in the line in which the bar of the Thomas hip 
splint runs, a piece of splint wood or a strip of malleable steel, 
long enough to reach from the middle of the back to the lower 
third of the thigh, should be incorporated in the plaster (Fig. 
JOT). A similar piece is sometimes placed in front of the hip 



Fig. 210. 



1— "^ 



A modification of the Lorenz hip rest used in the application of the plaster spica bandage. 
Another form is illustrated in the article on Congenital Dislocation of the Hip. 



and another beneath the knee, the points at which the bandage is 
likely to break. The proper anteroposterior support of the but- 
tock, consequently of the hip-joint, is almost invariably neglected 
in the ordinary application. The bandage may be applied in the 
upright posture by means of the swing, as used in the application 
of the plaster jacket, the weight being supported in part by the 
sound leg while the other is pendent. Or it may be applied with 
the patient in the reclining posture, the body being supported by 
a shoulder rest, and the pelvis by a sacral support. The arms 
are then drawn above the head to increase the capacity of the 
thorax, while the limbs are supported by an assistant (Fig. 213). 
In the more recent cases deformity may be practically reduced 
at the second application of the bandage, because of the relaxation 
of the spasm assured by the rest and fixation ; thus it is particu- 



TUBERCULOID DISEASE OF THE HIP-JOIXT. 



347 



burly useful iu the treatment of young children in the outdoor 

practice, for whom hospital care would otherwise be required. 

The Short or Lorenz Spica Bandage. The short spica 
bandage is used as routine treatment of hip disease in Lorenz's 

Fig. 211. 




The Lorenz spica, showing the adjustment to the pelvis. In this case it is extended belo* 
the knee, but in many instances motion at the knee-joint is perm 



clinic in Vienna unless direct weight bearing causes pain. It La 
applied in the manner described under the treatment of congenital 
dislocation of the hip, the aim being to tix the affected limb in 
an attitude of slight flexion and abduction, the primary attitude 
of hij) disease. A close-fitting covering of shirting i- di 



348 



ORTHOPEDIC SURGERY. 



Fig. 212. 



the limb and pelvis, and a wide bandage is then introduced 
between the skin and shirting to serve as a "scratcher." The 
bony prominences arc suitably protected by cotton or sheet wad- 
ding, and the bandages are then applied, being drawn closely 
about the pelvis and thigh, so that the movement joint may be 
controlled. The upper and lower extremities of the bandage are 
cut away as illustrated, and the shirting is then drawn over the 
margins of the plaster and sewed. This makes a smooth cover- 
ing and holds the padding in position. If the bandage is 
extended below the knee it is more efficient. As an adjunct to 
mechanical support and during the stage of recovery, or even in 
the treatment of cases of a mild type, the ban- 
dage is very satisfactory, but as a routine treat- 
vi^-J ^ ment it is not a sufficient protection. It should 
n^l ggjM be stated that in the treatment of the more acute 
; cases by Lorenz the weight of the body is re- 

! moved by a prolongation or stirrup of sheet steel 

which projects beyond the foot, the two extremi- 
ties being incorporated in either side of the 
plaster bandage in the neighborhood of the knee 
(Fig. 212). In the better class of cases a leather 
support provided with a steel foot-plate extending 
slightly below the foot and a joint at the knee 
is used. The short spica bandage in combination 

Uwith the traction hip brace (Fig. 220) answers 
the same purpose and is more efficient if some- 
what more cumbersome. 

Immediate Reduction of Deformity. In the more 
resistant cases an anaesthetic may be adminis- 
tered. If the deformity is due simply to mus- 
cular spasm the limb may be placed in the proper 
position without force, but if, as is often the case 
when the distortion is of long standing, it is caused 
in pari by shortening of the muscles and fasciae, a certain amount 
of force may be required. 

The pel\ is should be fixed and the force should be applied as 
far as possible by direct extension rather than by leverage. Sub- 
cut a neons division of the contracted tissues about the anterior 
superior spine and in the adductor region may be required. In 
very resistant cases the reduction of deformity by this method 
-lion Id be divided into several operations. Lorenz reduces the 
adduction deformity by means of a machine that exercises direct 



The Lorenz stilt, 
sometimes used in 
the treatment of tbe 
more painful cases. 
This is incorporated 
in the plaster ban- 
dage above the 
knee and it extends 
below the foot. 



TUBERCULOUS DISEASE OF THE HIP-J<>l\T. 



349 



traction on the adducted limb while the sound limb is pushed 
upward, so that practically no leverage is exerted on the joint. 1 
In cases in which the deformity is accompanied by abscess, or 
when the joint is surrounded by infiltrated tissues and by sinuses 
this treatment should not be employed. In fact, in certain cases 
of this class, especially when subluxation is present, it is often 
advisable to disregard the deformity that cannot be reduced by 
traction until the disease is cured, when it may be overcome by 
osteotomv of the femur. 



Fig. 213. 




The hip rest in use. The patient presents fixed flexion to 135 degrees, and fixed 
adduction of 35 degrees. 

The immediate reduction of deformity, properly performed, ie 
free from danger; and it lias become almost the routine of prac- 
tice in the indoor department of the Hospital for Ruptured and 
Crippled. The great advantage of placing the Limb in the proper 
position and fixing it for week- or months, instead of employing 
this time for the gradual reduction of the deformity, is, of course, 
self-evident. 



Lorenz. Sammltrag kiln. Vor.. 206, Leipzig, Mar 



350 



ORTHOPEDIC sriWEUY. 



Three methods of reduction of deformity have been described : 

1. By means of the traction brace. 

2. By means of the Thomas brace. 

3. By means of the plaster bandage, with or without anaes- 
thesia. 

A fourth method is that by means of the weight and pulley. 
This is in common use because it requires no special apparatus. 

Fig. 214. 



1 



W F 



Weight extension acting as leverage in hip disease. P, pulley ; W, weight ; F, fulcrum. 
Marsh's diagrams, illustrating the advantage of traction in the line of deformity, in order 
to avoid leverage. (Howard Marsh.) 

Reduction of Deformity by the Weight and Pulley. 
The traction plasters are applied to the limb in the manner 
already described and the patient is placed on his back on a 
narrow, firm mattress. The limb is raised until the lumbar 
vertebra? rest upon the bed and it is then moved to one or the 
other side, if lateral distortion is present, until the level of the 
pelvis is restored. In this position the limb is supported on a 
pillow, or, better, on the adjustable triangle used with the trac- 



FlG. 215. 




Posture of the limb in hip disease in which extension should be applied in order to avoid 
leverage. P, pulley ; W, weight : F, fulcrum. 

tion hip splint (Fig. 202). A pulley is then attached to the 
foot of the bed in a prolongation of the line of the flexed limb. 
The wheel may be screwed to the top of a narrow board, which 
may be raised or lowered on the foot of the bed as required. 
To the buckles on the plaster traction straps a stirrup carry- 
ing the cord is attached. This stirrup is simply a spreader of 
narrow, thin wood, slightly wider than the foot, provided at 
either cud with straps or tapes, its purpose being to prevent 
direct pressure on the malleoli (Fig. 219). By means of a 



TUBERCULOUS DISEASE OF THE HIP-JOINT. 



351 



weight suspended at the foot of the bed traction is made upon 
the limb to the extent that the comfort of the patient will per- 
mit As in Buck's system of extension, the foot of the bed is 
raised to increase the friction of the body and thus to counteract 
the traction force, but in the treatment of children this is ineffi- 
cient and counter-traction must be provided. A simple method 
is to attach two perineal bands, as described in connection with 
the traction brace, to strong tapes that pass above and below the 
patient's body, to be fixed to the head of the bed at a suitable 
distance from one another ; thus the pelvis is supported by pro- 
longed perineal bands. 

In order to assure efficient and constant traction the patient must 
be prevented from sitting up. For this purpose a swathe about the 
body or shoulder straps may be applied and attached to the bed. 



Fig. 216. 




Extension in hip disease. Marsh's method of fixing the patient in bed with shoulder 
straps and a long T-splint on the sound side. (Howard Marsh.) 



A convenient appliance is that of Marsh. " This consists of 
a piece of webbing, passing across the front of the chest and 
ending in two loops, through which the two arms are passed, 
and through which is threaded another piece of stout webbing, 
which runs transversely across the surface of the bed under the 
child's shoulders, and is fastened at its two ends to the sides of 
the bedstead. When this is in action the patient's shoulders 
are kept flat on the bed, so that he can neither sit up nor turn 
on his side. This chest band does not cause the slightest dis- 
comfort It is not, of course, fixed tightly, and when die child 
find- that he cannot sit up he makes no further attempt to do 
and as he lies flat the band i- loose/' 
It is often of advantage, particularly if the disease i- active, 
to use some form of apparatus to fix the patient more thoroughly. 



352 



ORTHOPEDIC SURGERY. 



Marsh uses a long lateral splint of thin board reaching from the 
axilla to a crossbar below the sole of the foot. To this the 
patient's body and sound limb are bandaged (Fig. 216). 



Fig. 217. 




Traction by means of weight and pulley. (R. T. Taylor.) 



Fig. 218. 




Method of fixing the patient to the Bradford frame for traction in hip disease. 
(R. T. Taylor.) 

For the same purpose a plaster spica bandage or a Thomas 
splint may be applied on the sound side, but a more convenient 
appliance is the frame of gas-pipe covered with canvas that has 






TUBERCULOUS DISEASE OF THE HIP-JOINT. 



353 



been described in the chapter on Pott's disease. Upon this frame 
the patient can be fixed, the limb being elevated by a support 
attached to the frame or independent of it (Figs. 217 and 218). 
It is perhaps needless to suggest that the bedclothes must be held 
from the elevated limb ; in fact, that the patient must for a time 
be enclosed in a tent of bedclothes if the deformity is extreme. 
At first the traction weight must not be great, but as the peri- 
neum becomes accustomed to pressure as much weight as can be 
tolerated is used, from ten to twenty pounds being the average. 
This may be reduced at night and increased during the day. 
Great care must be taken to prevent painful pressure on the 
perineum by careful adjustment and frequent inspection of the 
perineal bands. 

Fig. 219. 




Lateral and longitudinal traction in hip disease. (Page.) 



If the frame is used it may be provided with a windlass al 
the bottom for traction and with an arched baud of metal across 
the pelvis for the attachment of the perineal bands, which behind 
are fastened to the side bars at a higher level. Thus the frame 
may be made an independent recumbent splint on which the 
patient may be moved about. If, however, one desires to exert 
traction to the point of distraction, the weight and pulley arrange 
ment is more satisfactory: in this case the limb should be placed 
in an attitude of slight flexion and abduction, so thai the femur 
may be drawn more directly from the acetabulum. 

Lateral Traction. Tims far Longitudinal traction has been con- 
sidered, but lateral traction or traction in the line of the neck of 
the femur deserves some consideration. 



354 ORTHOPEDIC SURGER Y. 

Mr. Thomas, who condemned all forms of traction as deceptive 
and irrational, and especially longitudinal traction, speaks thus 
of lateral traction : " For surely if relief from pressure be 
required, the only direction in which this is possible is clearly in 
the axis of the neck of the femur. Any method of extension in 
the axis of the body merely transfers the pressure from the upper 
part of the acetabulum to the lower quarter." 1 This contention 
is purely theoretical, as there is no evidence to show that injurious 
pressure is ever exerted upon this part of the acetabulum. On 
the contrary, the specimens from subjects who have been treated 
by longitudinal traction in recumbency and by means of the trac- 
tion hip splint almost invariably show the effect of pressure upon 
the upper part of the head of the femur and upon the upper 
adjoining margin of the acetabulum. Moreover, the neck of the 
femur is in childhood so short and is set upon the shaft at so 
great an angle that longitudinal traction, if the limb be slightly 
abducted, is, practically speaking, in the line of the neck j so 
that even from the theoretical standpoint the question of injurious 
pressure could only arise in the treatment of adults. The advan- 
tage of lateral traction in the treatment of hip disease has been 
urged with great persistency by A. M. Phelps 2 since 1889, and 
it has been applied as a routine practice in ambulatory treatment 
by Blanchard, 3 of Chicago, since 1872. 

The effect of lateral traction in recumbency has been carefully 
investigated by C. G. Page. 4 His conclusions are that lateral 
traction alone is of no benefit, but if applied, together with lon- 
gitudinal traction, it gives great relief in certain acute cases. The 
longitudinal traction should be twice as great as the lateral, ten 
and five pounds being the average weights employed in his 
experiments. The method is shown in the illustration (Fig. 219). 

The Relative Efficiency of Traction and Splinting 
(" Fixation"). 

In considering the vexed question of the relative merits of 
splinting and traction in preventing muscular spasm and the con- 
sequent intra-articular pressure which causes pain and increases 
the destructive effects of the disease, these facts must be borne 
in mind. 



1 Loc. cit., p. 10. 2 New York Medical Record, May 4, 1889. 

f Transactions American Orthopedic Association, vol. vii. 

« C G. Page. Boston Medical and Surgical Journal, September 13, 1894. 



TUBERCULOIDS DISEASE OF THE HIP- JOINT. 355 

The more acute the disease the less ability of the joint to 
carry out its proper function, which is motion. The greater the 
motion under these circumstances the more intense the muscular 
spasm, of which the object is the prevention of motion. If 
it were possible, therefore, to fix the joint absolutely there should 
be no muscular spasm, although the tension of acute disease 
within the bone, or of its products within the joint, might cause 
pain. 

When the patient is fixed in the recumbent posture it is pos- 
sible to apply a sufficient traction upon the muscles to prevent 
the spasmodic contraction that causes injurious pressure, and 
although no amount of traction will absolutely prevent motion, 
yet with the support that the bed provides, practically speak- 
ing, complete rest may be assured. Only in the exceptional 
cases in which tension upon congested tissues about an acutely 
inflamed joint is intolerable is this method of treatment ineffi- 
cient. 

The same statement is true of a properly applied spica bandage 
or Thomas brace, when the patient is recumbent, that it assures 
practical rest ; thus it prevents muscular contraction, relieves the 
symptoms and promotes repair, although it cannot be claimed 
that the surfaces of the opposing bones are actually separated 
from one another. 

But what is true when the patient is recumbent is not true in 
ambulatory treatment. The traction exerted by the hip splint 
even when the limb is pendent is far less effective than in recum- 
bency, and when it is used as a walking appliance, for which it 
was designed and for which it is practically always employed, 
the traction is intermittent and of doubtful efficiency. The same 
loss in efficiency, although in far less degree, occurs in all forms 
of fixative apparatus when used in ambulation, but it may be 
stated without reserve that splinting is of far more importance 
in actual practice than is traction. 

The Removal of Direct Pressure. "Stilting." Granting thai 
the traction brace as a walking appliance is relatively inefficient 
in preventing motion, and that motion without friction, provided 
the joint surfaces are actually involved, is impossible, -till tin- 
traction brace is, or may be, at all times an effective still in thai 
it protects the joint from concussion and pressure by removing 
the foot from contact with the ground. 

It is true that the removal of dired pressure may be assured 
by the use of axillary crutches, but in Thomas' practi 



356 ORTHOPEDIC SURGERY. 

were used in but few cases. 1 In fact, it is only by constant super- 
vision that the use of crutches can be enforced upon children who 
no longer suffer pain ; and as it is practically impossible to pre- 
vent the patient from bearing weight upon the limb, stilting by 
this means is relatively inefficient. 

That direct pressure is one of the causes of upward displace- 
ment of the femur may be inferred from the statistics of Sasse 
and Bruns, 2 from the surgical clinics of Berlin and Tubingen, 
where the routine of treatment is the plaster bandage without the 
high shoe or crutches. In two-thirds of Sasse' s and in four-fifths 
of Bruns' cases there was upward displacement of the trochanter. 
This is certainly a larger proportion than would be found in a 
corresponding class of patients treated by efficient stilting, although 
statistics on this point from American sources are lacking. 

The Practical Combination of Traction. Splinting and Stilting. 
Thus far the methods of treatment by splinting and traction have 
been presented as if they were necessarily opposed to one another 
in principle, and as if the theory were still held that motion 
without friction is possible ; and as if it were believed that anchy- 
losis is caused by fixation and is prevented by the motion of a 
diseased joint. At the present time, however, it is generally 
recognized that the principle involved in both methods is the 
same, and that the actual merit of each must be decided by 
practical experience rather than by argument. The true test of 
the relative value of a routine of treatment is its efficacy in 
hospital practice, where its weak points cannot be supplemented 
by the careful supervision that may make almost any treatment 
effective that carries out in some degree the proper principle. 
This test is all the more necessary because the great majority of 
cases of this character are to be found among the poor. 

From this point of view the writer's experience may be of 
interest. His early training was entirely in the traction method, 
but the observation of a large number of cases in which this 
treatment was used led to the following conclusions : 

In one sense the treatment was successful, in that it in great 
degree relieved the symptoms throughout the course of the dis- 
ease and enabled the patients to go about in the open air, to 
attend to school, and even to join in the games of their fellows. 
It was evident, however, from an inspection of the patients as 

1 Ridlon. Loc. cit. 

2 Sasse. Arbeit aus der klin. Chir., Berlin, 1896. Bruns, Archiv f. klin. Chir., Bd. xlviii. 
H.l. 



TUBERCULOUS DISEASE OF THE HIP-JOINT. 357 

they returned for treatment, that the relief of symptoms was due 
to the protection insured by the stilting or crutch-like action of 
the brace and not by traction, which was usually simply traction 
in name, not in fact. But if the brace relieved the symptoms, it 
did not, in many instances, prevent deformity : and as the preven- 
tion of deformity is an object only secondary in importance to the 
relief of pain, the treatment was in so far unsatisfactory. This 
deformity was usually flexion, occasionally combined with adduc- 
tion, a deformity often increasing slowly without pain, or other 
evidence of greater activity of disease. If the deformity were 
reduced by traction in recumbency, it reappeared when ambu- 
latory treatment, by the brace, was resumed. This flexion seemed 
to be in many instances simply an adaptation to the prevailing 

Fig. 220. 




The short spica bandage reaching to the knee in combination with the brace. One perineal 
has been removed in order to show how the joint is supported by the bandage. The short 
spica of the Lorenz model may be used also for this purpose. 

postures. AVhen, for example, the patient assumed the sitting 
position, the limb was flexed in spite of the brace, and as much 
of the time was passed in this attitude, its influence on the pro- 
duction of deformity seemed to be obvious. 

It was also apparent that the brace was not effective in relieving 
pain during the more acute exacerbations, even during recum- 
bency with such traction as could be applied by the parents ; nor 
when the children were brought in arms to the clinic. 

Under these conditions it was found that acute symptoms 
might be relieved, or greatly modified, almost at once, by the 
application of a close-fitting short spica bandage extending from 
the middle of the thorax to the knee. Over this the brace un- 
applied as before, making an apparatus which then combined 
splinting, traction, and stilting (Fig. 220). This treatment w&e 



358 



ORTHOPEDIC SURGERY. 



repeated in many instances, always with the same result. As 
the application of the plaster bandage was a somewhat tedious 
proceeding, it was often exchanged for a short Thomas splint 
worn beneath the pelvic band of the traction brace in the same 
manner. This fixation appliance not only relieved pain in the 
acute cases, but it also prevented the deformity, which was not 
checked by the traction brace alone. 

Fig. 221. 




The long, inexpensive brace, with solid upright, showing the perineal bands and the 
adhesive plaster, as used in hospital practice. 



This combination of the short Thomas brace and the traction 
hip splint is effective as a means of relieving pain and preventing 
deformity. It has, however, the disadvantage of requiring careful 
adjustment, and it obliges the patient to wear shoulder straps ; 
in other words, much care must be exercised to insure the com- 
fortable adjustment of both appliances. Thus the next step was 
the combination of the two, even though the action was somewhat 



TUBERCULOUS DISEASE OF THE HIP-JOINT. 



359 



less effective. To the pelvic band of the traction brace a lateral 
thoracic bar was attached, reaching upward in the axillary line to a 
point opposite the middle of the scapula, where it was joined to a 
metal band that encircled the chest, like that of the Phelps brace. 
When this was securely fastened about the chest, the body and 
the limb were held in line by a long lateral brace; the pelvis 
was supported by the pelvic band and the joint received the 
additional protection that was assured by traction and stilting 
(Figs. 221 and 222). 

This brace and another form similar in principle, in which the 
upright of the thoracic attachment is fixed posteriorly to the 
pelvic band, are now in general use at the Hospital for Ruptured 
and Crippled. The efficiency of this brace may be still further 
increased by replacing the perineal bands by a metallic ring. 
This ring, which fits the upper extremity of the thigh closely, is 



Fig. 222. 




The long hip split applied. 



attached to the upright at an inclination corresponding to the 
line of the groin (Fig. 223). (The Thomas ring described fully 
in connection with his knee splint.) It is a better support 
because it prevents anteroposterior motion within the pelvic band, 
which the perineal straps allow. The ring may be used a- the 
only support or it may be combined with a perineal band on the 
opposite side. This is of advantage if there is a tendency toward 
adduction. 

The apparatus is most satisfactory when the hollow upright <»f 
the Taylor brace is used. This is light and strong, and is pro- 
vided with an arrangement for effective traction, but in hospital 
practice the upright i^ made- of solid metal, and the traction is 
made by simple Btraps. The metallic ring, besides providing 
better fixation, is a firm BUpport that cannot be removed by the 



360 



ORTHOPEDIC SURGERY. 



patient. It is, of course, more difficult of adjustment, and it is 
not suited to the treatment of youug children because of the 
difficulty in keeping it clean and dry. 

The Thomas ring was first applied to a hip splint by Phelps 
(Fig. 225). He has always urged the advantages of fixation and 



Fig. 223. 



Fig. 224. 




i ■ $' Jl 



The long brace, with Thomas ring and ex- 
tension upright, similar to Phelps' brace. 



Kear view of brace. 



traction, and his brace, of which that last described is simply a 
slight modification, is provided with an arrangement for lateral 
traction. Practically speaking, this is a tape by which the lower 









TUBERCULOUS DISEASE OF THE HIP- Jo I NT. 



361 



third of the thigh is held in apposition to the upright. It hardly 

seems possible that appreciable lateral traction can be exerted on 
the joint by this means if the metallic ring is properly fitted to 
the thigh. The simple straps do not afford as effective traction 
as the rack and pinion, nor is the brace, as usually constructed, 
sufficiently strong to bear the weight of the body without bend- 



FlG. 225. 



Fig. 226. 





The Phelps hip splint. 



A chair to be used with the long hip splint. The 
patient sits upon the sound side, while the splinted 
half of the body remains in the extended position, the 
brace resting on the floor. 



ing. It should be stated, however, that this form of brace is 
intended to be used with crutches rather than as a walking appli- 
ance. 

Many objections to this attempt to combine effective splinting 
without traction and stilting have been urged by those who believe 
in the efficiency of the ordinary traction brace. For example, ii ifi 
said that the splinting is ineffective because the movements of the 
trunk are transmitted to the joint, while this is aoi true of braces 
thai do not extend above the pelvis. In reply it may be Btated 
that the traction part of the combined splint remains as effective 



362 ORTHOPEDIC SURGER Y. 

as before ; thus it follows that this suggestion is an acknowledg- 
ment of the fact that the theory of motion without friction is no 
longer tenable. As a matter of experience, however, it will be 
found that motion of the upper part of the trunk is absorbed, as 
it were, in the flexible lumbar region of the spine before it reaches 
the joint. If, however, such motion or any motion causes dis- 
comfort or aggravates the symptoms, the patient should be con- 
fined in the recumbent posture until the acute phase of the disease 
is passed. 

It is said that the brace is cumbersome, that the patient cannot 
sit with comfort, and that it prevents normal activity. 

A long brace certainly weighs more than a short one, and if a 
brace prevents flexion of the hip and spine it is evident that the 
patient cannot sit with comfort in an ordinary chair. 

As a matter of fact, the patients themselves make little com- 
plaint of the brace, even when it has been substituted for an 
ordinary traction splint; while the greater restraint of activity 
is a favorable element of treatment, since children who do not 
suffer pain are much more likely to be too active than to be harm- 
fully restrained by any form of appliance. These objections are 
trivial, if one is convinced that the dangerous and deforming dis- 
ease that is under treatment may be more easily controlled and 
that the final result is likely to be better and to be more rapidly 
attained by this means than by another. 

It would be of advantage, of course, if a brace could be so 
adjusted to the pelvis and to the femur as to fix the joint without 
interfering with the motion of the spine. Satisfactory fixation 
can be attained, however, only by a close-fitting plaster bandage 
of the Lorenz model (Fig. 211). This should be applied over 
the traction plasters, and the traction hip brace is then adjusted. 
This method of treatment is the most effective that can be em- 
ployed, but it must be renewed at frequent intervals if " ideal " 
fixation is desired. 

This long brace is used exactly as is the ordinary traction 
brace. If deformity be present it is reduced by one or another 
of the methods that have been described. If the disease is 
acute, recumbency and traction are employed until this stage is 

When ambulation is resumed crutches may be employed for a 
time, but during the greater part of the treatment the brace is 
used as a walking appliance, as accurate splinting and as effective 
traction being employed during this period as circumstances will 



TUBERCULOUS DISEASE OF THE HIP JOINT. 



363 



Fig. 227. 




permit. If the joint continues to be sensitive the short spica 
plaster should be applied in the manner described, to be worn 
beneath the brace. If one desires to exert lateral traction the 
upper part of the thigh may be drawn outward by means of a 
bandage attached to the junction of the 
pelvic band and the upright of the 
brace. 

During the entire course of treat- 
ment supervision of the patient, with 
the aim of adapting activity to the local 
weakness, should be exercised, even 
though it may be less essential than 
when other apparatus is employed. 

The impression that one might re- 
ceive from descriptions of the treat- 
ment of hip disease is that most cases 
begin acutely, or that when the patients 
are brought for treatment the disease 
is in an acute stage, or that deformity 
is present, so that preliminary recum- 
bency is required. But each year the 
proportion of early cases is greater, 
cases in which there is no deformity 
and in which acute symptoms are ab- 
sent. In such instances the hip splint 
may be applied without preliminary 
recumbency, and if the joint is fixed 
in the normal attitude and protected 
a relatively rapid recovery without de- 
formity and with a fair range of motion 
may be hoped for. 

The Treatment of Hip Disease during 
the Stage of Recovery. It is much 
easier to assure one's self that the 
disease is still active than to decide 
when it is cured. For the symptoms 
may have been quiescent for months or 

years even, under the protective treatment, and yet they may 
recur on the slightest provocation when this treatment has beea 
discontinued. 

To judge of the probable duration of the disease in a given 
case, one must consider it- area, it- quality, and it- complica- 




The Taylor hip splint as used by 
Taylor in the later years of his 
practice with but one perineal 
band. 

The cut shows also an appliance 
for preventing or for correcting 
slight degrees of adduction, while 
the brace is in use as a walking ap- 
pliance. The abduction bar is 
buckled about the upper extremity 

Of the other thigh. (H. L. Taylor, 
Medical News, March 28, I 



3(34 



ORTHOPEDIC SURGERY. 



tions. If, for example, the primary symptoms indicate that the 
focus of infection is of limited area and is contained within the 
bone, rapid recovery, possibly in a year, may be expected ; but 
in the ordinary type of disease in which the joint has been 



FKi. 228. 




Taylor's median abduction brace used as a bed splint to overcome adduction by counter- 
pressure on tbe sound side. 

invaded, repair can hardly be anticipated in less than three or 
four years. Supposing that sufficient time has elapsed to permit 
of natural cure, if there have been no symptoms of active 
disease for a year or more, and if muscular spasm is absent, one 
may test the joint by removing the brace at night to ascertain the 



TUB EEC UL US BISEA SE OF THE HIP- JOIN T. 



365 



effect of simple motion without weight bearing. Such freedom 
will enable the patient to move the knee, which having been fixed 
in the extended position for so long usually remains stiff for a 



Fig. 229. 



Fie. 2.U-. 





J 



Judson's perineal crutch. This support 
suspended from the shoulders may be em- 
ployed as a substitute for axillary crutches. 
It is also used as a convalescent splint in the 
treatment of hip disease. 

time; in fact, several months 
may elapse before the full range 
of motion is regained. 

It is well, also, to remove 
the thoracic part of the brace to 
allow the patient more mobility 
at the hi]). At a later time the 
traction may be discontinued and 
the brace may 1>< suspended from 
the shoulders to serve as a per- 
ineal crutch | Fig. 230) ; or it 
may be attached to t!i«' shoe and 
so adjusted as to be slightly 
longer than tin- limb, in order that direct concussion and pressure 
may be lessened I iur. 229). Or a brace jointed al the knee, 
after the Taylor pattern, may be employed. 



Modified brace to be worn during conva- 
lescence. Same patient as in Fig. 224. The 
thoracic part has been removed and the 
lower end of the stem has been made into a 
caliper, passing through the heel of the shoe. 
The stem is extended by means of the key 
until the heel is lifted slightly from the shoe; 
thus the hip is relieved from shock. 



366 



ORTHOPEDIC SURGERY. 



This brace is so adjusted as to be slightly longer than the limb, 
so that the heel does not touch the bottom of the shoe (Fig. 232). 
Thus the weight is in great part supported on the perineal band. 
The weight of the brace may be in part supported and incidentally 



Fig. 231. 



Fig. 232. 





Convalescent hip splint, allowing motion at the knee. (Taylor.) 



slight traction may be exerted by adhesive plaster applied above 
the knee (Fig. 233). The foot plate, to which the upright is 
attached, is shown in Figs. 232 and 234. 

As the strain upon the part is increased, one watches carefully 
for the return of muscular spasm or for restriction of the range 
of motion. If the range of motion does not diminish, and if the 
deformity that may be present does not increase or does not 



TUBERCULOUS DISEASE OF THE HIP-JOINT. 



36' 



appear if it were absent, the brace may be removed at intervals and 
finally discarded. 

As has been stated, the short spica after the Lorenz model is 
an admirable support during the period of recovery. It prevents 
motion at the joint, yet it permits the function of support, and 
thus a gradual rebuilding of the bony structure which has become 
atrophied during the course of the disease. Bv means of this 



Fig. 233. 



Fig. 234. 



Fig. 235. 





Details of the Taylor convalescent hip brace. 
Fig. 233, the adhesive plaster. Fig. 234, the foot 
plate showing the method of attachment. 



The action of the Taylor ooni 
hip brace in removing dived | 

illustrated by wooden model 



appliance the limb may be held in the desired position of Blight 
abduction, and it is particularly effective when the limb, because 
of destructive changes in the joint, is inclined toward adduction. 

It should be stated that the long-continued fixation of the limb 
combined with traction may induce laxity of the I 



368 



oirnioi>i:i)ic surgery. 



hyperextension at the knee, unless it is properly supported by 
the posterior thigh band. In the cases in which the atrophy is 
extreme and in which this laxity is present the splint may 
be discarded in favor of the fixation bandage with advantage 
(Fig. 231). 

This period of supervision even in favorable cases should be 
protracted, for no patient can be considered free from the danger 
of relapse for a long time after apparent cure. If there is firm 
1» my anchylosis, as in exceptional cases, cure is assured; but if 
there is simple fibrous anchylosis, and particularly if there is 
upward displacement of the trochanter, there is a strong ten- 



Fn». 236. 




Double hip disease, terminating in bony anchylosis. 

dency toward flexion and adduction, even though the disease 

7 © 

is cured. In such cases it is often necessary to employ appar- 
atus at intervals to reduce the deformity or to hold the limb in 
proper position until stability is assured. When the brace has 
been discarded, the patient should be trained to walk with equal 
steps, placing the limb, as far as possible, on an equality with its 
fellow and adapting in like manner the stronger to the weaker 
member. 

This has an important influence; in checking the tendency to 



TUBEECULOUS DISEASE OF THE HIP-JOINT. 



369 



deformity and in modifying, or even concealing, the limp, a point 
to which Judson has repeatedly called attention. 

Bilateral Hip Disease. 

Xmety-five cases of bilateral hip disease were treated in the 
Hospital for Ruptured and Crippled during a period of ten years 
ending in 1899. 

As a rule, the second hip is affected some time after the symp- 
toms of disease of the first have been apparent, but occasionally 
both joints are involved simultaneously. In most instances the 
symptoms are rather subacute, owing, very likely, to the fact 
that the activity of the patient is so restricted. 



Fig. 237 




Left hip disease, showing swelling caused by abscess, also the absence of flexion deformity. 



Treatment. The treatment is similar in principle to that of 
the unilateral form. The patient during the greater part of the 
course of the disease must be confined in the recumbent position, 
although not necessarily in bed. The double Thomas hip splint 
is a convenient means of fixation. AVith this apparatus extension 
by means of the weight and pulley may be employed, or Un- 
brace may be so modified as to provide independent traction. If 
the disease of one hip is acute and is attended by abscess forma- 
tion, excision for the purpose of lessening the strain upon the 
patient may be advisable. 

If motion is greatly restricted in both joint- locomotion unl< — 
crutches are used is very difficult, n- motion at tin- kna 
supply only in small part the function of the hip-joints In such 
instances excision of one hip in the hope of obtaining ;i ■ 
amount of motion may be considered. 

24 



370 



ORTHOPEDIC SURGERY. 



Hip Disease Combined with Disease of Other Parts. 

The most common combination is with Pott's disease. The 
two processes may be primarily distinct, but occasionally it would 
appear that the disease of the hip is caused by the infection of an 

abscess, which, coming from 

Fig. 238. ,i • j. ' i 

the spine, remains tor a long 
time in contact with the cap- 
sule of the joint. In five of 
one hundred and fifty cases of 
disease of the hip-joint of 
which the final results were 
reported by Gibney, Water- 
man, and Reynolds (page 387), 
Pott's disease was a complica- 
tion, in two instances preced- 
ing and in three following the 
disease at the hip. The com- 
bination of the two diseases 
makes the mechanical treat- 
ment difficult. Recumbency 
offers the best opportunity for 
the effective adjustment of 
apparatus when the disease of 
either part is acute. At a 
later period crutches may be 
employed, together with the 
necessary braces. 

Hip Disease in Infancy. 

Hip disease in infancy is 
far less common than in early 
childhood. It presents noth- 
ing of special interest except 

Untreated hip disease. Slight flexion and ° . * 
adduction (apparent shortening). The scar of that its effect Upon the IUnC- 
a former abscess is seen on the outer aspect of , • £ ,1 • • < i n ,1 

the lhigh tion of the joint and upon the 

development of the limb is 
usually more marked than in older subjects. Tuberculous disease 
of this joint must be differentiated from infectious epiphysitis, in 
which prompt operative treatment is indicated. A modified 
Thomas brace is most efficient in treatment (Fig. 208). 




TUBERCULOUS DISEASE OF THE HIP-JOIXT. 371 

Hip Disease in the Adult. 

Hip disease in the adult may present the typical symptoms of 
the ordinary form, but it is usually of the more subacute type. 
Not infrequently it is a complication of tuberculosis of the lungs. 

The subacute form of tuberculous disease is often difficult to 
distinguish from osteoarthritis, if this is confined to the hip- 
joint. Gonorrheal arthritis and impacted fracture of the neck 
of the femur may be mentioned also in differential diagnosis. 
The mechanical treatment is not difficult, but in many instances 
early excision may be advisable in order to bring about a rapid 
cure of the disease. This is far more important than in child- 
hood, because few adults can afford the time required for the 
natural cure, and because in many instances the general con- 
dition of the patient may demand relief from the depressing 
effects of the local disease, especially if it be complicated by 
suppuration. 

Abscess in Hip Disease. 

It may be assumed that a limited collection of the fluid prod- 
ucts of the tuberculous process is present in nearly every case of 
hip disease in which the joint surfaces are actually involved. In 
many instances it remains within the joint. In a larger propor- 
tion of the cases the capsule is perforated, the fluid escapes, and, 
if the quantity is sufficient to form an appreciable tumor, it is 
classed as an abscess. Such abscesses may be detected in about 
50 per cent, of the cases that are treated under ordinary con- 
ditions. 

In 1370 final results collected from various sources the per- 
centage of abscess was as appears in the following table : 

39 cases reported by Shaffer and Lovett 1 69 percent. 

82 ' Gibney- 60 " 

390 " " " Bruns, :i Tubingen 68.8 " 

568 " " " Koenig, 4 Giittingen 66.5 " 

126 " " " Sasse, 5 Berlin 50 

82 " " " Prendlsburger, Vienna .... ">1 

84 " in private practice, C. F. Taylor" . . . .26 " 

Most often the abscess first appears upon the anterior and 
upper part of the thigh, in the space between the sartorius and 

New York Medical Journal, May 21, It 
2 New York Medical Record, March 2, I 
z Beit, zur klin. Chir., 1896, Bd. xxx. 

* Die Spec. Tuberculose der Knoch u Gclenke, Berlin, 1902. 
'■ Arbeit au« der Cbir. klinik del K. Univ. Berlin (Bergmann'l < 
6 Behanrl. der Gelenktaberculose and Inn der klinik Albert, u l< 

: Boston Medical and Surgical Journal, March 6, U 



372 ORTHOPEDIC sritoEJiY. 

tensor vaginse femoria muscles. In other instances it may be 
detected first on the inner side of the thigh, or it may form a 
tumor beneath the gluteal muscles, its situation being influenced 
by the point at which the capsule is ruptured. 

In rare instances the acetabulum may be perforated and a 
pelvic abscess may be formed, or the pus may find its way into 
the pelvis along the iliopsoas muscle ; and occasionally a pelvic 
abscess may exist which appears to have no direct communica- 
tion with the joint. 

According to Koenig 1 the weakest point of the capsule is in 
the anterior wall, where it is covered by the iliopsoas muscle and 
by its bursa, which often communicate with the joint. A second 
weak place is in the posterior wall. 

In a total of 321 abscesses in hip disease recorded by Koenig 
the situation was as follows : 

On the inner side (inside the femoral artery) 26 

Front of the joint (between artery and anterior superior spine) . 126 

Region of the trochanter 63 

Posterior surface 49 

In the pelvis 41 

In other situations 16 

The tuberculous abscess is a symptom and common accompani- 
ment of hip disease, which, in cases treated under proper condi- 
tions, is not of great importance ; and yet, on the other hand, it 

Fig. 239. 




A 1 -cess in hip disease. The brace is provided with the Thomas ring and with the 
ratchet extension. 

is recognized as a dangerous complication. It is dangerous to 
life because of the profuse suppuration that may follow infection, 
and to function because of the adhesions and contractions that 

1 Loc. cit. 



TUBERCULOUS DISEASE OF THE HIP-JOIST. 373 

may result. This is evident in all statistics. It is clearly shown 
in those of Brims. In this list the mortality in the non-sup- 
purative cases was 23 per cent., and of the suppurative 5 '2 per 
cent. 

The Significance of Abscess. If abscess appears early in the 
course of the disease, it usually indicates that it is of a destruc- 
tive character, and that the interior of the joint is involved ; 
therefore, perfect function is less likely to be preserved than in 
those cases in which the disease has been confined to the interior 
of the bone. 

Abscess formation is often preceded by an acute exacerbation 
of symptoms, by pain, by an increase of muscular spasm and 
consequent distortion, and often by an elevation of temperature. 
These acute symptoms subside and a fluctuating swelling appears. 
It may be inferred that the pain in such a case was due to the 
tension of the abscess within the capsule, and that the relief of 
pain followed perforation and the escape of the fluid. 

In perhaps the larger proportion of cases, more especially 
those in which the joint has been protected, the formation of the 
abscess is not preceded by acute symptoms, such as have been 
described. Its appearance is long delayed, and but for the swell- 
ing its presence would not be suspected. 

As the progress of the disease is influenced by the strain and 
injury to which the part is subjected, so abscess, a symptom of 
disease, is more common in those cases in which early and 
efficient treatment has been neglected; for the same reason it- 
subsequent course is directly influenced by the protection that 
the diseased joint receives. 

The danger from abscess is, of course, infection. Occasionally 
the abscess may become infected before an opening form-. Such 
infection may be inferred when the tissues about the abscess are 
hot and sensitive, and when fever is present; but, as a rule the 
abscess is sterile until the skin is perforated. If the absa - 
is small and if drainage is efficient, and especially if communica- 
tion with the joint ban been occluded, infection is of slighl con- 
sequence. But if before the. opening has formed the abscess has 
perforated intermuscular fasciae and has extended between the 
layers of muscles in various directions, infection is likely to cause 
severe local and constitutional symptoms. The thigh becomes 
the seat of an infectious cellulitis, pockets of pus form, which 
cannot be properly drained; hectic, emaciation, and loss oi appe- 
tite follow, and if the profuse discharge of pus persists amyloid 



;J74 ORTHOPEDIC SURGERY. 

degeneration of the internal organs may result. Such patients 
are said to die of exhaustion but the cause of exhaustion is an 
infected abscess. 

Treatment. Admitting that abscess is a symptom whose 
importance stands in direct relation to the care that has been 
exercised in the treatment of the disease, and that in the better 
class of cases the danger from this source is slight, still it is also 
true that abscess is the chief cause of danger, and almost the 
only cause of death, in hip disease per se. One's views as to the 
treatment are likely to be influenced by the class of cases with 
which he is most familiar. Some surgeons have advocated abso- 
lute non-interference with the symptomatic abscess on the ground 
that in many instances it finally disappears by spontaneous 
absorption, while in other cases the long delay allows the com- 
munication with the joint to close, so that the danger of infection 
after an opening has formed is slight. Finally, that the results 
after non-interference are better than those reported after opera- 
tive treatment. Others insist that all collections of fluid of this 
character should be evacuated as soon as they are discovered, 
because of the danger of infection before an opening forms and 
because of the advantage gained by preventing burrowing of 
pus. Little could be said against this latter course were it not 
that infection is as common after operative treatment as when a 
spontaneous opening forms ; the only advantage in favor of the 
artificial opening being that the cavity with which it communi- 
cates should be smaller and more direct than when the fluid 
has undermined the tissues in various directions, but this is offset 
by the fact that at least 20 per cent, of abscesses disappear with- 
out treatment. In fact, as compared with indiscriminate incisions, 
the let-alone treatment should be preferred when proper after- 
treatment cannot be assured. 

It would appear, however, that the middle course, between the 
extremes, is the safest, and especially so, as by far the larger 
number of patients must be treated under conditions that do not 
permit of proper care. In the outdoor department of the Hos- 
pital for Ruptured and Crippled abscesses are treated symptoraat- 
ically. If a swelling appears but remains quiescent and causes 
no symptoms, it is not disturbed. If it enlarges, the tension of 
the fluid is relieved by aspiration, which may be repeated as 
required, compression, after the evacuation of the fluid, being 
applied by means of a pad and bandage. If the abscess is on 
the point of opening spontaneously, or if its contents are of such 



TUBERCULOUS DISEASE OF THE HIP-JOINT. ;;:;, 

a nature that aspiration is impossible, an incision is made and 
the proper dressings are applied; or, if the child lives at a dis- 
tance from the hospital, the mother is instructed in the manner 
of dressing and as to the importance of cleanliness. 

If the abscess is of large size, or if acute symptoms are present, 
the child is admitted to the hospital. Here the same general 
principle is followed, but at the present time the routine of treat- 
ment of non-infected abscess is free incision that will allow com- 
plete evacuation of its contents. The abscess membrane is 
removed by gently rubbing with iodoformized gauze. If the 
opening in the capsule of the joint is exposed, this may be en- 
larged to permit the evacuation of the products of disease within 
the joint ; at the same time the character and extent of the dis- 
ease may be ascertained, and foci may be removed if practicable ; 
the wound is then closed with superficial and deep sutures, and a 
firm dressing is applied. This operation, if performed under 
aseptic precautions, causes no disturbance, and it relieves nature 
from the burden of necrotic material which must be an obstacle 
to spontaneous absorption. In many instances the abscess is 
permanently cured, although if the condition that induced it re- 
mains unchanged fluid will again accumulate, and if so a spon- 
taneous opening will form in the line of the incision. This oper- 
ation is not a radical cure of the abscess or of the disease ; it 
is simply a means of thorough evacuation for the purpose prima- 
rily of accomplishing what the aspirator does only in part. If 
the abscess has become infected its contents are completely 
removed, the wound is then packed with gauze, and provision 
is made for efficient drainage. 

In the treatment of abscesses the injection of iodoform emulsion, 
in connection with the aspiration or incision has been thoroughly 
tested. The results, as far as the disappearance of the absoi se 
was concerned, were not as good as from simple aspiration ; and 
as the procedure, being somewhat of the nature of an operation, 
caused the patients some discomfort and anxiety, it was discon- 
tinued. From the clinical standpoint there is little evidence 
that these injections exercise any particular influence upon tin- 
disease, but, theoretically, iodoform should lessen the infectious- 
>f the tuberculous fluid, and by local irritation stimulate (lie 
growth of granulation tissue. There appears t<» be no serious 
objection to its use. 

The Treatment of Sinuses. When tin- disease is active the 
sinuse- that serve as drain- should not \x- interfered with. And 



376 ORTHOPEDIC SURGER Y. 

in the advanced cases when the disease is quiescent and when 
the tissues about the joint are of the peculiar, resistant, " porky " 
consistency, active measures, either for the purpose of closing 
sinuses or for the correction of deformity, should be de- 
ferred. In many instances, however, sinuses persist as tuber- 
culous fistuloe, serving no useful purpose. In this class the com- 
plete removal of the infected tissue by excision or by thorough 
curetting is the most effective remedy. The various applications 
of pure carbolic acid, solution of salicylic acid, iodoform emul- 
sion, balsam of Peru, and the like are of some service, but 
thorough removal of the disease is the only radical treatment. 

Exploratory Operations. In certain instances exploratory opera- 
tions may be indicated. If, for example, pain and swelling indi- 
cate tension within the capsule it may be relieved by an incision 
and the joint may be explored with the possibility of finding a 
localized focus of disease that may be removed. 

The joint may be opened by an anterolateral incision, begin- 
ning one inch to the outer side of the anterior superior spine and 
extending downward about three inches. This exposes the line 
of junction between the tensor vaginae femoris and the gluteus 
medius muscles. When these are separated from one another the 
anterior surface of the capsule of the joint is laid bare. If more 
room is required the tensor vaginae femoris muscle may be 
divided. The capsule is then incised in the line of the neck and 
through the incision the head of the bone may be extruded by 
rotating the limb outward and extending it. By this means the 
character of the disease may be ascertained and in certain in- 
stances localized foci in the neck or in the head of the bone may 
be removed. The wound is then closed or drained as may seem 
advisable. By such intervention the course of the disease may 
be shortened, although cure by this means is unusual. 

Temporary anterior dislocation of the head of the femur by 
means of the anterolateral incision may be of value in acute and 
painful disease. Posterior dislocation for this purpose has been 
performed by Bradford in several cases with satisfactory results, 
the bone being again replaced when the disease had become qui- 
escent. 1 The object of this operation is to remove the opposing 
bones from direct contact, and to relieve the muscular spasm that 
accompanies acute disease. 

Kxploratory operations also may be of special value in the 

1 Transactions of the American Orthopedic Association, vol. xiii. 



TUBERCULOUS DISEASE OE THE HIP-JOIST. 377 

later stages of the disease, to ascertain the cause of long-con- 
tinued suppuration, or of abnormal delay in repair, which may be 
due to detached or adherent fragments of necrosed bone within 
the joint. This point is illustrated by the statistics of 61 cases 
of hip disease treated by excision by Poor. 1 In 15 of these loose 
bone was found in the joint, and in 7 the head of the bone was 
detached. 

In 98 cases investigated by Lehman 2 at the Wiirzburg Clinic 
sequestra were present in 20.4 per cent, and in 70 per cent, of 
88 cases treated by Riedel. 3 

An exploration of the joint by one familiar with surgical 
technique should be free from danger, and it may be of much 
value. 

Excision of the Hip. The operation of excision is now classed 
as a treatment of necessity in certain cases, usually those in 
which recovery under conservative treatment is considered very 
doubtful. For example, when there is progressive failure in 
health ; when it is impossible to drain the joint effectively after 
infection ; when there is evidence of extension of the disease to 
the shaft of the femur or to the pelvic cavity, or when other 
serious complications exist. 

In certain instances the excision may follow an exploratory 
operation ; in such cases the anterolateral incision may be em- 
ployed and the neck and head of the bone only may be removed. 
In this operation the diseased tissue is removed as thoroughly as 
possible with the sharp spoon, by scrubbing with iodoform i zed 
gauze, and by flushing with hot water. If the joint is not 
infected it is dried ; iodoform emulsion may be injected or the 
pure carbolic acid may be applied, and the various tissues are 
then sewed in layers ; pressure is applied, the aim being to secure 
immediate union. If this does not take place drainage is 
employed in the usual manner. 

In typical cases the operation is performed because of exten- 
sive disease and infected abscess, and in such in-t ;m«-«-< the rutin 
upper extremity of the bone to the trochanter minor is removed. 

A satisfactory method is that of Koenig. 

An incision about five inches in Length i- made in a line join- 
ing tin- trochanter and the posterior inferior spine of tin- ilium. 
About two-thirds of the length i> above and one-third over tie- tro- 
chanter. The incision is deepened to expose tie- capsule and the 

.v York Medical Journal. April 23, 1892. KTttrzburg, I - 

•ralbl f. Chir.. 1893, Bd. xx., Hos. 7 and 8. 



378 ORTHOPEDIC SURGER Y. 

surface of the trochanter, from which one removes the insertion 
of the gluteus maximus and the tendons of the medius and 
minimus. The muscles are separated in the line of the incision 
and the capsule is widely opened. With a thick, strong knife 
one separates all the muscular attachments to the anterior margin 
of the trochanter, while the limb is rotated outward, removing, 
if possible, a thin section of periosteum and bone. The same 
process is then repeated on the posterior surface, the limb being 
rotated inward. The trochanter is then removed. 

The acetabular insertion of the capsule, together with the 
adjoining upper border of the acetabulum, is then cut away and 
the neck of the femur is separated from the shaft with a saw 
or chisel. All the diseased parts are then removed, including 
the acetabular wall and adjoining bone, if necessary. The wound 
is partly closed with drainage, and the extremity of the femur is 
placed within the acetabulum, where it should be retained for a 
time by a plaster bandage or Thomas brace provided with trac- 
tion straps. When the patient begins to walk a hip splint or 
other support is used for a time to prevent deformity. One of 
the most efficient supports of this class is the short or Lorenz 
spica, the limb being fixed in an attitude of overextension and 
moderate abduction for many months. 

The success or failure of excision of the hip as a life-saving 
operation, provided the diseased bone has been removed, is de- 
cided by the after-treatment, and in this, drainage is the great 
essential. The opening must be large and the shaft of the bone 
must be drawn down by efficient traction, so that it may not ob- 
struct the opening, and the exuberant granulation must be 
removed from time to time. Phelps has introduced a valuable 
adjunct in the use of short, glass drainage tubes of large diameter, 
even up to one and one-half inches. Through such a tube or 
speculum the gauze is inserted, the opening permitting thorough 
inspection. 

The importance of an open-air life after these operations can 
hardly be exaggerated. The lack of this, the inefficiency of the 
after-treatment in securing proper drainage, and the postponement 
of the operation until amyloid changes are advanced explain the 
unsatisfactory character of the results. 

The functional results after excision in this class of cases are 
not as good as those that may be obtained when the operation has 
been performed at an earlier period. If motion continues free the 
joint is usually insecure. In many instances there is upward 




TUBERCULOUS DISEASE OF THE HIP-JOIST. 379 

displacement of the shaft of the femur upon the ilium with con- 
sequent flexion and adduction deformity, while in a third class of 
cases a movable joint of sufficient strength may be preserved. 
The ultimate shortening is considerably greater than after con- 
servative treatment. This is accounted for by the upward dis- 
placement of the femur and by the removal of the two epiphyses 
of its upper extremity. 

In a period of twelve years, 1888 to 18 99, inclusive, 149 opera- 
tions of excision were performed at the Hospital for Ruptured and 
Crippled. During this time 1283 cases of hip disease were treated 
in the wards and 1870 new cases were recorded in the out-patient 
department. Thus the operation was performed in 11.6 per cent, 
of those in the hospital, but the relative frequency of the opera- 
tion in the entire number of patients under treatment was con- 
siderably less than this. 

One hundred and twenty-one of these operations of excision, 
or those performed prior to 1897, have been carefully analyzed 
by Townsend. 1 The 121 operations were performed on 119 
patients, in two instances both hips having been operated upon. 
In 113 abscesses or sinuses were present, in most instances 
infected. In 5 cases the spine was involved as well as the hip ; 
in 2 instances the knee ; in 2 the tarsus ; in 3 the ilium. In 24 
cases the anterior incision was employed, in 97 the posterior. 
In 18 instances the acetabulum was seriously diseased, and in 
10 osteomyelitis of the shaft of the femur was present. This 
indicates the character of the disease in the cases operated 
upon. 

In 99 of the 119 cases the later results of the operation were 
ascertained. Of these 52 were dead and 47 were living. Of the 
52 deaths 9 were due directly to the operation, shock ; 28 were 
caused by exhaustion (persistent suppuration); 9 by tuberculoma 
meningitis; 7 by other causes. Thirty-seven deaths occurred 
within six months and 10 others within one year of the operation. 
Of the 47 patients living at the time of the investigation, 26 
were cured. Of the remaining number about one-half were in 
poor condition, so that recovery could not be expected. It 1- 
evident that in a large proportion of tie- cases the operation was 
unsuccessful as a life-saving measure, since suppuration per- 
d. 

The functional results in these cases are shown in the follow- 
ing table : 

1 Medical News, Jui;< 



380 



oimroPEDic surgery. 



Table Showing Shortening, Motion, Number of Sinuses Present, 
and Angle of Greatest Extension in Forty-seven Cases of 
Excision. (Townsend.) 



No. 


Time since 


General con- 


Sinuses 


Angle of 

greatest 

extension. 


Motion in 


Shortening 


operation. 


dition. 


present. 


degrees. 


in inches. 


1 


6% years 


Good 


3 


150 





2V 2 


2 


6% " 


Fair 


1 


135 





4 


3 


6 " 


Good 





180 


100 


3 


4 


5^ •■ 







180 


35 


3 


5 


5% " 
&A " 


Fair 





145 


10 


4 


6 


Good 


1 


165 





1% 


7 


5 " 


" 





155 


5 


1% 


8 


4K " 
*A " 
4K " 


" 


3 


160 





2 l A 


9 


" 





160 





2% 


10 


" 





165 





iy* 


11 


4 


" 





150 





1A 
lA 


12 


4 


Poor 


4 







13 


%A " 
3K " 


Good 





155 





IK 


14 


" 





160 


30 


l 


15 


3 " 


Poor 


1 


165 





% 


16 


2 


Fair 


2 


145 


30 


% 


17 


2 


Good 










18 


2 " 


Fair 


1 


170 





A 


19 


2 " 


Good 





150 





3 


20 


1H " 


" 





175 




A 


21 




" 





165 


30 


A 


22 


" 





150 





l 


23 


1% " 


1 < 





150 





lA 


24 


1% " 


" 


1 


180 





X A 


25 


l& " 


Fair 


6 


175 


15 


l 


26 


1 " 


Poor 


2 


165 





2K 


27 


1 


Good 





170 





VA 


28 


1 


" 





155 





l 


29 


1 " 


" 





175 





v% 


30 


1 


Poor 





180 


10 


*i 


31 


11 months 


" 


3 


170 





32 


10 


" 





180 


40 


V/k 


33 


10 


Good 


3 


165 





A. 


34 


10 


" 





160 





A 


35 


10 


" 


1 


165 





l 


36 


10 


Poor 


1 


160 





% 


37 


10 


Good 


3 


155 


10 


IK 


38 


9 


" 


1 







A 


39 


9 


" 









A 


40 


9 


Poor 


1 


170 


"6 


A 


41 


9 


Fair 


3 






l 


42 


8 " 


Good 





180 


130 


8 


43 


8 » 


" 





180 




44 


8 " 


Poor 


1 


165 


i'6 


% 


45 


7 


" 










46 


7 


Good 





180 


10 


v-A 


47 


7 " 







160 


70 


V. 



Lovett 1 has reported the results of 50 excisions in a similar 
class of cases at the Boston Children's Hospital, 1877 to 1895. 
The number of patients actually treated in the wards of the hos- 
pital is not stated, but 1100 cases were recorded as having been 
under treatment during this time, a percentage of excisions of 
4.5 of the total number. In 8 of the cases osteomyelitis of the 
femur was present, and in 15 the acetabulum was perforated. 
The ultimate mortality was about 50 per cent. 

Poor 2 has reported the results in 65 cases operated upon at St. 



Transactions American Orthopedic Association, vol. x. 
New York Medical Journal, April 23, 1892. 



TUBERCULOUS DISEASE OF THE HIP-JOINT. 381 

Mary's Hospital, Xew York, with a final mortality of about l;> 
per cent. In 21 cases osteomyelitis of the shaft of the femur 
was present. In 11 cases there was perforation of the acetabulum, 
and in 9 of these the opening communicated with an intrapelvic 
abscess. 

These statistics are quoted to illustrate the relative efficiency 
of late excision. The extent of the lesions in some of the cases 
shows that recovery would have been impossible without opera- 
tion, and its failure to relieve the symptoms in so many instances 
is sufficient evidence that it was postponed too long. Under 
proper conditions for treatment excision of the hip is almost 
never required, but in hospital practice it should be performed 
oftener and earlier in the course of the disease. 

Amputation. Amputation at the hip should follow excision 
when suppuration persists and when the condition of the patient 
does not improve, provided the internal organs are not hopelessly 
diseased. The operation of amputation after complete excision is 
a simple procedure and it should not be attended with great danger. 

Reduction of Deformity in Resistant Cases. The various methods 
of reducing deformity during the active stages of the disease have 
been described, and the importance of preventing deformity 
throughout the entire course of treatment has been insisted on. 
At the present time, for one reason or another, deformity from 
this cause is very common, either because its importance is not 
appreciated or because it is considered as a necessary concomitant 
of the disease, treated by apparatus, as it is in the natural cure. 
At all events, in many instances it is allowed to persist until the 
accommodative changes about the diseased joint have so fixed tin; 
limb in the deformed position that greater correcting force is 
required than can be applied by the weight and pulley or by 
other method of traction. 

In this class of cases, in which the muscles arc structurally 
shortened and in part transformed to fibrous tissue, and in which 
the anterior wall of the capsule has become retracted and it may 
be adherent to the surrounding parts, forcible reduction under 
anaesthesia, or osteotomy, may be required. If the disease is 
quiescent or cured, if the head of the femur or what remains <»f 
it is in the normal position, and if a fair range of motion re- 
mains, gradual forcible reduction, after division of the bands of 
fascia or the muscles that hold the limb in the deformed position, 
i- advisable. 

In all cases in which the head of the articulat 



382 



ORTHOPEDIC SURGERY. 



the aim should be to secure an anterior transposition of the upper 
extremity of the femur, and to secure this result one proceeds 
as in reducing or transposing the congenitally displaced hip — 
by longitudinal traction, by forcible abduction, combined with 
massage of the adductors, and, finally, by gradual extension — 
preceded usually by division of the resistant parts about the 



Fig. 240. 




Extreme deformity after hip disease, showing the attitude hefore operation. 
(See Figs. 241 and 242.) 



anterior superior spine. The limb is then fixed by a Lorenz 
spica in an attitude of moderate abduction and overextension. 
Later the abduction is lessened by the overextended position ; this 
is maintained for many months, and is assured by passive move- 
ments after the support is removed. Forcible reduction in cured 
or quiescent cases is practically free from danger. 

The Correction of Deformity by Femoral Osteotomy. If the 
deformity is fixed by bony anchylosis or by firm, fibrous adhesions 
within the joint ; or if it is feared that violence may stimulate 



TUBERCULOUS DISEASE OF THE HIP JOIST. 



383 



dormant disease; or if there is such a degree of upward displace- 
ment of the femur upon the pelvis that the deformity is Likely to 
recur after replacement, it is better to correct the deformity by an 
osteotomy of the femur. 

The patient having been prepared for operation, is turned upon 
the side and a sand-bag is placed between the thighs. A small 
osteotome, about the shape of a lead-pencil, of which one extremity 
is flattened to a cutting edge (Vance's instrument), is pushed 
directly through the soft parts to the femur at a point about two 
inches below the apex of the trochanter. It is turned until its 
cutting edge is at the right angle to the shaft and it is then 
driven through the cortical substance of the bone. When it has 
penetrated at one point it is withdrawn, and adjoining portions 
are cut until about half the circumference is divided, when with 



Fig. 241. 




The favorite attitude in recumbency. (See Fig. 240.) 



slight force the bone may be fractured. If the deformity is of 
long standing, division of the contracted tissues in the adductor 
region and below the anterior superior spine may be required. 

The limb is then drawn down to complete extension and 
moderate abduction, and the body and limb are encased in a 
plaster-of- Paris spica bandage, which should remain in position 
for several months, although the patient may be allowed to bear 
weight on the limb in a few weeks after the operation. The long 
may be replaced by the short spica at the end of two months. 
This latter or some similar appliance should be used until testa 
-how that there is no longer danger of recurrence of the deformity. 

The advantages of the subcutaneous method are simplicity and 
freedom from danger. No dressings are required, except a pad 
of gauze over the minute opening, thus the limb may be firmly 
held by the plaster bandage. If there is anchylosis between the 
femur and the pelvis uo support will be required after the bone 



384 



ORTHOPEDIC SURGERY. 



Fig. 242. 



has united, but if there is motion in the joint some fixative appli- 
ance should Be employed for a time to prevent recurrence of a 
part of the deformity. 

Prognosis. Mortality. The direct mortality of hip disease is 
due almost entirely to the immediate or remote effects of abscess. 

This is illustrated by the statistics of 
Bruns, in which the mortality from all 
causes of the non-suppurative cases was 
23 per cent, as compared with 52 per 
cent, in those in which suppuration was 
present. 

The mortality among the patients 
treated at many of the German clinics 
is much higher than in the corresponding 
class in this country. 

At Tubingen, according to Wagner, 1 
it was 40 per cent. 

At Kiel, according to Mummelthy, it 
was 48.59 per cent, in non- operative 
cases and 53.96 per cent, in operative 
cases. 

At Marburg, according to Marsch, it 
was 35 per cent, in non-operative cases 
and 40.4 per cent, in operative cases. 

At Heidelberg, according to Huis- 
mans, 2 it was 46.6 percent, in non-oper- 
ative cases and 58 per cent, in operative 
cases. 

At Zurich, according to Pedolin, 3 it 
was 37.7 per cent, in non-operative cases 
and 54 per cent, in operative cases. 

At Vienna, according to Prendls- 
burger, 4 it was 17 per cent, in all classes. 

At Gottingen, according to Koenig, 5 
40.3 per cent. 

In a total of 636 cases treated by conservative methods by 
Rabl, 1859 to 1894, definite results were ascertained in 519 ; 6 




After correction by osteotomy 
and division of the contracted 
tissues. (Gibney.) (See Figs. 240 
and 241.) 



1 Beit. z. klin. Chir., 1895, Bd. xiii. 

2 Quoted by Binder, Zeits. f. Orthop. Chir., 1889, Bd. vii. JJ. 2 and 3. 

* Centralbl f. Chir., July 25, 1896, No. 30. 4 Loc. cit. 

'■> Koenig. Das Hoeftgelenk, Berlin, 1902. 

6 Zur Conserv. Behand. der tuberculosen Knochen und Gclenksleiden, J. Rabl, Leipzig 
und Wien, 1895. 



TUBEECULOUS DISEASE OF THE HIP-JOINT. 

335 were hospital eases. Of these 216 were cured, 64. 1 per 
cent.; 70 died, 20.8 per cent., and 49, 14.4 per cent., were still 
under treatment; 184 were treated as out-patients. Of these, 
132 were cured, 71.5 per cent. ; 35 died, 19.2 per cent., and 17, 
92 per cent., remained under treatment. 

In 288 cases treated at the Hospital for Ruptured and Crippled, 
Xew York, reported by Gibuey, 1 the death-rate was 12.5 per 
cent. 

In private practice the statistical reports of final results show 
the death-rate to be extremely small. C. F. Taylor, 2 94 cases, 
including 24 in which suppuration was presented, 3 deaths. 
L. A. Sayre, 3 212 cases, 5 deaths. Lorenz, 4 60 cases, with 3 
deaths. 

In the clinics of this country the death-rate has been estimated 
to be from 10 to 15 per cent., a rate of mortality much lower 
than that reported from those abroad. This is accounted for in 
part by the fact that patients are of a better class and in part 
because they receive earlier and more efficient mechanical pro- 
tection. 

The causes of death, according to Wagner's statistics of 124 
cases, were as follows : 

Hip disease 35 

General tuberculosis 37 

Tuberculous meningitis 13 

Tuberculosis of the lungs 11 

Acute miliary tuberculosis 5 

Amyloid degeneration 8 

Septic infection 12 

Intercurrent disease . . 3 

124 

Thirty per ceut. of the deaths occurred in the first year of the 
disease, 26 per ceut. in the second year, and 20.4 per cent, in the 
third year. 

The percentage of recovery was 65 per cent, of those in fche 
first decade of life, 56 per cent, of those in the second, and but 
28 per cent, of those in the third decade. 

The causes of death in 50 cases among 77s patients treated ;it 
the >"f;w York Orthopedic Dispensary and Hospital during the 
years 1877 to 1882 were : 5 



1 New York Medical Journal, July and August, 1877. 

- Boston Medical and BargfcaJ Journal, March 6, 1879. 

' New York Medical Journal, April 80, l- 

« Wiener Klinik, 1892, 10 and 11. 

* Shaffer and Lovett. New York Medical Journal, Ma; 

25 



386 ORTHOPEDIC SURGER Y. 

Tuberculous meningitis 20 

Amyloid degeneration 5 

Exhaustion 3 

Tuberculosis of the lungs 3 

Tuberculous peritonit s 1 

Septicaemia 1 

Convulsions 1 

Unknown 16 

50 

Of 96 deaths recorded at the Alexandra Hospital, London (a 
mortality of about 26 per cent, of the cases treated), the causes 
were 

Tuberculous meningitis . 16.1 per ct. 

Albuminuria and dropsy 20.8 " 

Tuberculosis of the lungs 8.3 " 

Exhaustion 9.4 " 

Erysipelas and pyaemia 3.1 " 

After operation 9.4 " 

Intercurrent diseases 7.3 " 

Unknown 25.0 " 

100.0 

The direct mortality of hip disease should include all deaths 
due to operation, those caused by exhaustion and amyloid degen- 
eration, which is almost always the result of profuse suppuration 
secondary to pyogenic infection. Tuberculous meningitis, a com- 
mon and apparently an unavoidable cause of death, is not neces- 
sarily a complication of the local disease, except in so far as a 
lowered vitality may predispose the patient to it, since it may 
have been due to new infection or induced by the primary focus 
which preceded the tuberculosis of the hip. 

It is believed that operative interference is sometimes the direct 
cause of tuberculous meningitis, and it is of interest in this con- 
nection to note that 20 of 50 deaths, or, rather of 34, in which 
the cause of death was known, 58 per cent, were due to this 
complication among the cases treated at the New York Ortho- 
pedic Dispensary and Hospital, where no operations were per- 
formed. 1 While of 52 deaths in a total of 99 cases treated at 
the Hospital for Ruptured and Crippled, in which excision was 
performed, but 9 were caused by tuberculous meningitis. 2 

The normal death-rate among cases under fair hygienic condi- 
tions is illustrated by statistics from the Hospital for Ruptured 
and Crippled at a time when no operative or mechanical treat- 
ment was employed. 3 This was 12.5 per cent. ; 4.5 per cent. 
from exhaustion, 4.5 per cent, from amyloid degeneration, 1.75 

1 Shaffer and Lovett. New York Medical Journal, May 21, 1887. 

- Townsend. Medical News, June 26, 1896. 

3 Gibney. New York Medical Record, March 2, 1878. 



TUBERCULOUS DISEASE OF THE HIP-JOINT. SS7 

per cent, from tuberculous meningitis, 1.75 per cent, from inter- 
current diseases. 

Thus nearly 75 per cent, of the deaths were due more or less 
directly to suppuration. 

Functional Results. In a certain proportion of cases perfect 
function may be retained, the proportion depending upon the 
extent of the disease, and upon the timeliness and efficiency of 
the treatment. 

In a total of 280 cases from the private practice of Dr. L. A. 
Sayre, 1 in which the final results were known, 73, or 26 per 
cent., recovered with perfect motion, and 120, or 42 per cent., 
retained good motion. These results are extraordinarily good, 
very much better than any others that have been reported, and, 
of course, far better than may be expected in the ordinary class 
of cases. 

The effect of mechanical treatment and of the various measures 
employed for the correction of deformity is well illustrated in 
two series of ultimate results in cases treated at the Hospital for 
Ruptured and Crippled, reported by Gibney. 2 In the first series 
of 80 cases no mechanical or operative measures were employed, 
the treatment being simply hygienic and symptomatic ; the 
results, therefore, represent natural cure under proper super- 
vision. The duration of the disease was three years in 23 ; three 
to six years in 28 ; six to ten years in 16, and fifteen years in 
one case. 

In 35 cases the shortening was two inches or more, and in 
nearly every case there was more or less deformity, viz. : 

In 2 there was flexion to 90° 

" 3 " " 110 

" 3 " " 120 

'• 19 " " " 135 

" 19 " " " H". 

"18 150 

" U " «' 1' 

In 4 no estimate was made. Distortions other than flexion 
an- not specified. 

In \'l instances motion was retained of from 15 to !»i» deg 
In the second series 3 of 107 cured cases mechanical ami opera- 
tive treatment was employed, although the protection assured 
was in many instances far from efficient. In many of these 
the disease was in an advanced Btage, and deformity was pi 

1 New York Medical Journal, April 80, I 

2 Gibney, Waterman, and Reynolds. Trans. Amer. Ort) xi. 



388 ORTHOPEDIC SURGEB Y. 

in more than half of the number when treatment was begun, and 
yet all of them recovered without marked flexion and presumably 
without adduction, as this deformity is not mentioned. 

No flexion 47 

Flexion of 10° 30 

" of 10-20° 20 

" of 20-30° 10 

Perfect motion was retained in 13 

Good " " " 22 

Limited " " " " 41 

There was anchylosis in ....*.... 31 

In 69 cases the shortening was one inch or less, 35 having no 
shortening. In 38 it was more than one inch. 

As has been stated, the mechanical treatment in these cases 
was not sufficiently effective to prevent deformity, and to attain 
these results osteotomy with or without division of contracted tis- 
sues was performed in 19 cases, forcible correction with or with- 
out tenotomy in 30 cases, and in 4 cases the joint was excised. 

If the joint has been actually invaded by disease so that a part 
of its articulating surface has been destroyed, motion must be 
impeded both in area and quality. In such cases the joint is 
somewhat weakened, and it is often sensitive, although in many 
instances not to the extent of interfering seriously with the ability 
of the patient. In this class discomfort in damp weather or pain 
on overexertion is experienced, symptoms similar to those com- 
plained of by rheumatic subjects. 

Simple shortening, due to retardation of growth, unaccom- 
panied by deformity, is of comparatively little importance. 
Firm anchylosis in a symmetrical position insures a strong and 
useful limb, the flexibility of the lumbar region compensating for 
the loss of motion at the joint. In such cases the disability may 
be very slight, and the effect of the loss of motion may be more 
apparent in the sitting than in the erect posture, for the patient 
must, as it were, sit upon his back, an attitude which perceptibly 
reduces the sitting height. 

Flexion, if it be slight, does not cause disability, but flexion 
of more than 30 degrees increases the lumbar lordosis and makes 
the buttock prominent, the deformity so characteristic of the 
natural cure (Fig. 1 90). Great flexion, for example, of 60 or 90 
degrees, causes an exaggerated lordosis which is almost always 
a source of pain or discomfort to a patient who is obliged to stand 
much of the time. 

Abduction is of no importance unless it be considerable. It 



TUBERCULOUS DISEASE OF THE HIP-JOINT. 389 

serves in most instances as a compensation for actual shortening 
of the limb. 

Adduction, on the other hand, which necessitates an upward 
tilting of the pelvis in order to restore the parallelism of the 
limbs, is the most disastrous of all the distortions since it causes 
a practical shortening often greater than that due to the destruc- 
tive effects of the disease. 

The motion that is retained after recovery from hip disease is 
usually considered as the. test of successful treatment. This is 
by no means the fact, for in many instances motion is preserved 
because the joint is destroyed and because what remains of the 
upper extremity of the femur is supported by the tissues on the 
dorsum of the ilium — a form of pathological dislocation. 

In such cases deformity is almost always present, and the sup- 
port is insecure. 

Deformity is far more disabling than loss of motion, and the 

sf safeguard against final deformity is to prevent it during 
treatment, and to retain as far as may be the joint surfaces in 
proper relation to one another. Whatever motion is preserved 
will then be of service to the patient, and if anchylosis follows 
the result may still be classed as good. 

Deformities of Other Parts Caused by Hip Disease. Deformities 
of other parts are sometimes observed as secondary r< Bults of hip 
disease, most often in cases that have not received proper treat- 
ment. In the spine an exaggerated lordosis as a compensation 
for flexion is not uncommon, and lateral curvature may follow 
distortion of the pelvis caused by adduction. In the limb hnoch- 
nay follow persistent adduction of the thigh, or it may be 
an effect of laxity of the ligaments without such distortion. 
Another deformity is genu reeurvatum. This is apparently caused 
by long-continued disuse of the limb, and by the use of apparatus 
in which the knee has not been properly supported. Ii is sup- 
posed to be one of the effects of traction, but it is also observed 
in cases in which traction has never been employed. In cases in 
which the muscular atrophy that follows limited motion and long- 
continued disuse is great, laxity of thi ligaments of the knee-joint 
is common, and not infrequently subluxation of the tibia also. 
A slight degree of equinus with accompanyii eration of the 

arch is not uncommon among patients who have been treated by 
the traction apparatus, in which the foot is pendent and in which 
the toes are often inclined downward to guide the brace in walk- 
ing. Practically speaking, all these secondary deformities may 



390 ORTHOPEDIC SURGER Y. 

be avoided by proper supervision of the patient during the period 
of treatment. 

As a rule, patients who have recovered from hip disease finally 
discard all apparatus, or at most use only a cane as a support, 
and many prefer to walk habitually on the toe rather than to 
equalize the length of the limbs by a high shoe. 

By far the larger number of this class, having accommodated 
themselves to whatever weakness and distortion may be pres- 
ent, are able to undertake the ordinary occupations of life. Of 
the patients cured at the New York Orthopedic Dispensary and 
Hospital in the report already referred to, in whom the final 
results as regards motion and symmetry were certainly not above 
the average, it is stated that there was not a single individual 
who was incapacitated from doing a full day's work at his or her 
trade or occupation. None used crutches and but one used a 
cane. 



CHAPTER VIII. 

NON-TUBERCULOUS AFFECTIONS OF THE HIP-JOINT. 

The relative frequency and importance of the various affec- 
tions of the hip-joint that cause disability are indicated by the 
following statistics of Koenig's 1 clinic at Gottingen : 

Tuberculous disease 568 = 75 per ct. 

Infectious diseases after typhoid fever : 

Scarlatina and the like 110 

Gonorrheal arthritis 30 

Arthritis deformans 22 

Injuries 11 

Contractions, cause unknown . . . . 6 [ 

Coxa vara 5 i 

Tumors 2 I 

Pyaemic suppuration 3 i 

757 

Several of the affections enumerated are very uncommon in 
childhood, while injury and coxa vara are relatively more im- 
portant. Coxa vara and fracture of the neck of the femur in 
early life are considered in Chapter XY. 

Traumatisms at the Hip -joint. 

It is probable that injury at the hip-joint, caused by falls or 
strains, may induce congestion about the epiphyseal cartilage of 
the head of the femur. In this class of cases there is usually 
discomfort at night after overexertion, "growing pain," and 
there may be a limp and restriction of motion. These symp- 
toms may disappear in a few days or they may recur from time 
to time. If the injury is more severe there may be local sen- 
sitiveness and even swelling — synovitis. This congestion, with 
the lessened local resistance induced by it, may be a predisposing 
cause of tuberculous disease. It is probable, also, thai 
this type are sometimes mistaken for hij> disease ;ui«l go to 
the number of perfect functional results that are attained by one 
or another system of treatment. 

Treatment. All cases of tlii- class require careful treatment 
and supervision. Strains or other injuries in young children are 

" DasHoeftgelenk.Herlin, I 



392 ORTHOPEDIC SURGERY. 

best treated by a supporting bandage and by rest in bed until 
the symptoms disappear. If the sensitive condition persists, 
protective treatment by a brace, preferably the ordinary traction 
hip splint, or by a short plaster bandage, should be employed, 
the diagnosis being reserved until it is made clear by the progress 
of the case. Chronic synovitis of the hip-joint, especially in 
the adolescent or adult, unless it be a result of severe injury, is 
usually tuberculous in character. 

Fracture of the neck of the femur, epiphyseal separation, and 
coxa vara are considered in another section. 

Acute Infectious Arthritis— Acute Epiphysitis at the Hip-joint. 

Acute epiphysitis, caused by infection with pyogenic germs, is 
not uncommon in infancy and early childhood, and it often 
passes as a form of acute tuberculous disease. Of fifty-two cases 
in which but a single joint was involved the hip was affected in 
twenty-six. 1 In some instances it is induced or favored by 
injury, in others it is secondary to an infected wound, and it may 
follow pneumonia or one of the exanthemata. (See page 270.) 

Symptoms. The symptoms are of sudden onset, accompanied 
usually by high fever and prostration. The hip becomes swollen, 
hot, and sensitive both to motion and pressure. 

Treatment. The treatment is early and free incision and 
efficient drainage, the limb being afterward supported by some 
form of splint. The suppuration ordinarily persists for several 
months ; the epiphysis is usually destroyed in whole or in part, 
and in consequence the joint becomes somewhat loose and flail-like 
(Fig. 243). Many of these cases seen in later years, but for 
the history and the scars about the joint, might be mistaken for 
congenital dislocation. In certain instances the symptoms are 
less acute and the diagnosis from tuberculous disease can be 
made positively only after a bacteriological examination of the 
fluid that may be removed from the joint by aspiration. 

In the class of cases in which the disease is confined to one 
joint and in which the shaft of the bone is not involved, the 
prognosis is good if the pus is thoroughly evacuated. In twelve 
cases treated at the Hospital for Ruptured and Crippled there 
were three deaths. 2 The prognosis as to function under these 
conditions is much better than in tuberculous disease. 



1 Townsend. American Journal of the Medical Sciences, January, 1890. 
- Townsend. Loc. cit. 



NON-TUBERCULOUS AFFECTIONS OF THE HIP-JOINT. 393 

After recovery the joint should be supported for a time to 
prevent upward displacement. If the head of the femur has 
been destroyed there is usually upward and backward displace- 
ment. This induces flexion and adduction of the limb and great 
disability. In such cases one should, under anaesthesia, force the 
femur forward to the neighborhood of the anterior superior spine 
and to lix it there for a long period by the application of a 
Lorenz spica bandage applied with the limb in an attitude of 
abduction and hyperextension. The operation is in detail similar 
to the Lorenz method for replacing the congenital dislocation. 
(See Congenital Dislocation of the Hip.) 

Subacute Arthritis. 

In the forms of arthritis that may complicate infectious dis- 
eases several joints are usually involved, and the affection is 
often subacute in character. 

Undoubtedly there are mild cases of infection at the hip-joint 
terminating in partial or complete recovery without operation. 
In such cases, which are usually classed as rheumatism, there is 
usually some infiltration about the hip, flexion deformity, limita- 
tion of motion, and pain or discomfort referred to the affected joint. 
A satisfactory treatment is the application of ichthyol ointment 
in a strength of about 25 per cent., the joint heing fixed by a 
posterior wire splint or light Thomas hip brace. 

Spontaneous Dislocation of the Hip-joint. 

If the hip-joint becomes distended with fluid the capsule may 
be ruptured and sudden displacement may occur. 

Degez 1 lias collected from literature seventy-nine cases of this 
character. The displacement occurred in the course <>f the fol- 
lowing diseases : 

Typhoid fever 

Rheumatism -' 

Scarlatina 13 

Variola 

Gonorrhoeal arthritis 

Orippe 

Erysij^elas l 

Eruptive fever . 1 

Such accidents 2 may be guarded against by preventing flexion 

and adduction of the limb and by evacuation of the fluid that 

1 Revue d'Orthop''die, January 1. I 

.raff. Itenu 



394 



ORTHOPEDIC SURGERY. 



Fig. 243. 



distends the joint. The femur should be replaced as soon as 
possible before it has become fixed by adhesions and contrac- 
tions. Even in this class of cases, in which treatment has been 
delayed for months, by means of preliminary traction and by 
the use of manual force, as in the reduction of congenital disloca- 
tion, one may succeed in replacing the femur. In cases of long 
standing the acetabulum is filled with new material, which must 

be removed by the open method be- 
fore replacement is possible. As an 
alternative operation one may force 
the head of the femur into the an- 
terior position and fix the limb, for 
several months, in the attitude of 
extension and abduction. If the 
outward rotation of the foot is exces- 
sive, or if a tendency toward adduc- 
tion persists, a secondary osteotomy 
of the shaft below the trochanter 
minor may be performed. How- 
ever early, reduction is accomplished, 
limitation of motion is to be expected, 
and in many instances absolute an- 
chylosis. On this account the limb 
should be supported for a time in 
proper position in order to prevent 
deformity. 

Gonorrhoeal Arthritis. 

Gonorrheal arthritis of this joint 
is an affection not uncommon in adult 
life, and in its symptoms and effects 
it may resemble tuberculous disease 
or perhaps more closely osteoar- 
thritis. The treatment of infectious 
arthritis in general is discussed else- 
where. Deformity should be cor- 
rected by rest in bed with traction, and protective treatment 
should be employed while the sensitiveness persists. The short 
spica plaster bandage, if properly applied, is a satisfactory sup- 
port. 




The later effect of acute epiphysitis 
of the right hip at three months of age. 
The scar is shown. 



XOX-TUBEECULOUS AFFECTIOXS OF THE HIP-JOIXT. 395 

Extra-articular Disease. 

Occasionally tuberculous disease, or other form of destructive 
ostitis, may begin in the neighborhood of the trochanter major. 
The symptoms are local pain, sensitiveness, and swelling of the 
soft parts. Later thickening and irregularity of the underlying 
bone become evident. 

The symptoms are limp and discomfort. If the disease in- 
volves the capsule or is sufficiently acute to cause sympathetic 
congestion of the joint, there may be limitation of motion ; but, 
as a rule, this is slight or absent. In many instances the focus 
in the bone may be shown by an X-ray negative. When the 
disease is tuberculous or of the subacute type, abscess in the 
trochanteric or gluteal region may be the first indication of 
disease. 

The treatment is prompt removal of the focus of disease before 
the joint or the shaft of the femur has become involved. 

Disease of the pelvic bones in the neighborhood of the joint 
may simulate hip disease. The diagnosis is made by the local 
swelling and sensitiveness, and by the freedom of motion in the 
directions not restrained by sensitive tissues that are involved 
in the disease. 

Gluteal Bursitis. An enlargement of one of the bursa? lying 
beneath the gluteal muscles may cause a rounded, fluctuating 
swelling in the buttock. It may be painful to pressure and it 
usually causes a limp and some discomfort on motion, dependent 
upon the degree of inflammation that may be present. Occasion- 
ally the bursitis may be caused by injury, but in most instances 
it is the result of tuberculous infection. The bursa may com- 
municate with a diseased hip-joint, but usually it is a distinct 
and primary affection. 

Iliopsoas Bursitis. The iliopsoas bursa lies in front of the 
capsule of the hip-joint, extending from the trochanter minor to 
and sometimes over the brim of the pelvis. Not Infrequently 
it communicates with the joint. If the bursa is enlarged it 
forms a swelling in Scarpa's space of a somewhat quadrilateral 
form. Sometimes a central indentation indicates the position of 
the iliopsoas tendon. 

This causes a distinct enlargement of tin- upper and inner aspect 
of the thigh. It is usually accompanied by slight flexion, abduction, 
and outward rotation of the limb, an attitude that relieves the 
tension on the sensitive part. Zuelzer ha- collected from litem- 



396 ORTHOPEDIC SURGER Y. 

ture forty -five cases of gluteal and fifteen of iliopsoas bursitis. 
This illustrates the relative frequency of the two affections. 1 

Simple bursitis may be distinguished from disease of the joint 
by the absence of characteristic muscular spasm and general limita- 
tion of motion. Acute inflammation may simulate local abscess. 

Treatment. Chronic disease of bursa? is usually tuberculous 
in character. Aspiration and injection of carbolic acid or iodo- 
form emulsion may be employed as primary measures. As a 
rule, however, incision, drainage, or, if possible, removal of the 
sac is indicated. According to Lund, 2 iliopsoas bursa may be 
reached easily by a vertical incision between the femoral artery 
and the crural nerve. 

Malignant Disease about the Hip-joint. 

Carcinoma of the upper extremity of the femur is almost 
always secondary to a primary tumor of another part of the 
body. Sarcoma is far less frequent in this situation than at the 
knee. The character of the disease soon becomes evident in the 
general enlargement of the upper extremity of the thigh, but in 
the early stage diagnosis can be made only by means of the 
X-ray or by exploratory incision. 

Cysts of the Fenlur. 

In extremely rare instances cysts, caused apparently by inclu- 
sion of a displaced portion of epiphyseal cartilage, may cause 
enlargement, weakening, and deformity of the upper extremity 
of the femur. One case, in a boy thirteen years of age, was 
treated at the Hospital for Ruptured and Crippled. The symp- 
toms were discomfort, limp, and outward bowing of the upper 
third of the femur. Cure followed its removal. Cysts may be 
caused also by localized osteomyelitis of a mild character. 

Arthritis Deformans. 

Osteoarthritis of the Hip-joint. Osteoarthritis is not infre- 
quently confined to the hip-joint. In this form it is an affection 
of adult life or old age (malum coxse senile). It is characterized 
in its later stages by disappearance of the cartilage covering the 
head of the femur and by an eburnation and progressive destruc- 
tion, or wearing away, of the underlying bone. At the same time 

i Deutsche Zeits. f. Chir., Bd. 1. H. 1 and 2. 

2 Boston Medical and Surgical Journal, September 25, 1902. 



XOX-TUBEECULOUS AFFECTIONS OF THE HIP-JOIST. ;\\\- 

there is formation of ecchondroses about the junction of the femur 
with the acetabulum, which become ossified into irregular masses 
of bone. In the early stage of the affection the fluid within 
the joint may be increased in amount, but later it is diminished 
in quantity and changed in quality as the synovial membrane 
becomes transformed in part to fibrous tissue. The etiology of 
the affection is discussed elsewhere. (See page 274.) 

Symptoms. The early symptoms are usually subacute in char- 
acter. They are neuralgic pain in the limb, " sciatic rheumatism," 
stiffness on changing from rest to activity, and sensitiveness to 
direct pressure on the joint, so that the patient often lies habitu- 
ally on the other side. The movements of the joint become 
somewhat restricted, and in certain instances creaking sounds 
are apparent to the patient. In the advanced stages of the dis- 
ease there is marked thickening about the trochanter which is 
usually displaced upward, owing to the progressive changes in 
the head and neck of the femur. The limb is shortened and it is 
often distorted, usually in an attitude of flexion and adduction, 
and marked atrophy is apparent. These symptoms, but for the 
history, might be mistaken for the results of fracture of the neck 
of the femur, and in the earlier period of the disease the limp, 
the pain, and restriction of motion with the attendant atrophy 
may simulate very closely tuberculous disease of a subacute 
type. 

The progress of the disease may be slow or it may be rapid. 
It depends in great degree upon the strain to which the part is 
subjected. In this it resembles tuberculous disease. 

Treatment. In the class of cases in which the disease is con- 
fined to a single joint one may hope to check the progress of the 
destructive process by lessening the strain upon the joint by 
regulation of the patient's habits and occupation, and to improve 
the nutrition of the part by massage and local stimulants. 
ve motion in the directions of abduction and extension for 
the purpose of preventing secondary contraction of the muscles, 
is of service also. 

If deformity be present it should be reduced by tract inn and 
rest in bed. Afterward the symptoms may be relieved by the 
use of a hip brace (Fig. 231) that will remove the weigh! and 
limit the range of motion, or a support of the charact 
a Lorenz spica of plaster, Leather, or other material may be 
used. In extreme cases resection of the upper extremity of the 
femur might be advisable. Lorenz states that I ■• 



398 ORTHOPEDIC SURGER Y. 

cases satisfactorily by inducing anterior transposition of the 
head of the femur and fixing the limb for a time in an attitude 
of extension and abduction. In most cases neither the operative 
nor the brace treatment is feasible, but the use of a firm flannel 
spica bandage or similar support, combined with the application 
of cautery, from time to time, adds to the comfort of the patient. 



CHAPTER IX. 



TUBERCULOUS DISEASE OF THE KNEE-JOINT. 



Fig. 244. 



Synonyms. White swelling, tumor albus. 

Tuberculous disease of the knee-joint is next in frequency and 
importance to that of the hip. It is, however, far less dangerous 
to life, and the prognosis, as regards function, is much better than 
in the former affection. This is explained by the simplicity of 
the joint and by its situation at a distance from the trunk, at the 
junction of two levers of nearly equal length and size. As the 
problem of protection by mechanical means 
is comparatively simple it is more often 
applied, and in proportion to its efficiency 
the injury of functional use is lessened 
and the tendency to deformity is checked. 

Pathology. The disease may begin in 
the epiphysis of the femur or in that of 
the tibia, occasionally in the patella or in 
the head of the fibula, or primarily in the 
synovial membrane. 

In 547 cases, 1 about two-thirds of which 
were in adults, treated at Koenig's clinic 
at Gottingen by operative procedures 
which permitted inspection of the joint, 
281 (51.4 per cent.) were apparently ex- 
amples of primary osteal disease ; 266 
(48.6 per cent.) were primarily synovial. 
The focus was in the femur in 93 in- 
stances (33.1 per cent.), in the tibia in 
107 (38.1 per cent), in the patella in 33 
(11.7 per cent.), and in more than bone 
in 48 (17.1 per cent.). 

The examination of a joint permitted by arthrectomy or excision 

cannot be sufficiently thorough to exclude diaeaaeof the bone and 

rtablish the diagnosis of primary disease of tin- synovial mem- 




\ 



>i 



..n of Itnee-joinl at the 

d eight yean, showing 

the epiphyses <>f the femur and 

tibia and their relation i<» the 

acation in i' 
of the femur and tibia 

],r.s.-nt tit birth. <K-ilir.'iti<>ii 

la completed In each at about 
otletb year. 



•ecielle Tubercul' - 



400 ORTHOPEDIC SURGER Y. 

I) nine, but iu 92 instances the opportunity was offered by ampu- 
tation at the thigh, 80 of the patients being adults. This 
examination, presumably thorough, showed the primary disease 
to be of the bone in 50 cases, while in 35 the synovial membrane 
was apparently the seat of the primary affection. 

In 17 of the 50 cases in which the disease was osteal, the focus 
was in the femur ; in 7 it was in the internal condyle, in 6 in 
the external condyle, and it was in other situations in 4 cases. 
In 17 the primary disease was of the tibia ; in 5 of the internal 
tuberosity ; in 5 of the external tuberosity ; in other situations 7. 
In 5 instances the primary disease was of the patella, and more 
than one bone was involved in 11 cases. Nichols 1 states that he 
has examined 120 tuberculous joints of adults and children, after 
excision or amputation, or at autopsy, and in every instance pri- 
mary foci in the bone were discovered. He believes primary disease 
of the synovial membrane to be very uncommon, and asserts that 
examinations are of no particular value as establishing the absence 
of primary osteal disease unless the bones are sawed into thin 
sections. This is the view generally held in this country, that in 
the great majority of cases the disease of the bone precedes the 
disease in the interior of the joint. From the clinical standpoint, 
however, one recognizes two distinct types of tuberculous dis- 
ease : one, beginning as a chronic synovitis of which the early 
symptoms are subacute, a type more often seen in adults (Fig. 
248) ; and the more common class, in which the symptoms of 
pain, muscular spasm, and deformity seem to indicate clearly 
primary disease of the bone. 

The proximity of the active disease in the neighborhood of the 
joint sets up a sympathetic hyperemia within it, and an accom- 
panying synovitis. If the disease is progressive the synovial 
membrane becomes thickened and adhesions form between its 
folds that gradually lessen the capacity of the joint and diminish 
its mobility. When perforation takes place the granulation 
tissue spreads over the surface of the cartilages, destroying them 
in its progress and eroding the underlying bone ; or if the joint 
is filled with tuberculous fluid the cartilage may be macerated and 
separated in necrotic shreds. The direct destructive effects of the 
disease are increased by pressure and friction if the joint is not 
protected by mechanical means. The hypertrophied synovial mem- 
brane and the thickened and diseased capsule explain the peculiar 

1 Transactions American Orthopedic Association, vol. xi. 



TUBERCULOUS DISEASE OF THE KXEE-JOINT. 401 

elastic resistance on palpation called pseudofluctuation. In more 
advanced cases there is also a reactive inflammation in the over- 
lying tissues, accompanied by a formation of fibrous tissue thai 
involves the tendons and muscles. These changes within and 
without the joint cause the firm, resistant tumor characteristic of 
" white swelling." 




Flexion deformity at the knee-joint, with slight subluxation of the tibia. 

Etiology. The etiology of tuberculous disease has been dis- 
cussed in Chapters V. and VII. 

Statistics. Tuberculosis of the knee-joint is essentially a dis- 
ease of early life, although it is less strictly confined to childhood 
than is disease of the spine or hip. Sex exercises but little 




After forcible correction, showing the increase of the posterior displacement 
from the X-ray photographs of an uctnui 



Drawing* 



influence, and the two Bides are affected in Dearly equal aumbers. 
Tl i ese points are illustrated by the following table of L000 con- 
secutive cases treated at the Hospital for Ruptured and Crippled. 1 

1 These statistics, together with those of taberc 
hip, were collected for rne by Dra. K. C Brads '<■ ,1 "' 1 -■ u 

Stone, house officers at the hospital, 1900-1901. 

26 



402 



ORTHOPEDIC SURGERY. 



Age at . 


[NCI 


[PIENCY OF 


Knee-joint 


Di 


SEA 


3E. 






1 year or less 


. 25 


23 years old 12 


2 years old . 








. 45 


24 " 










8 


8 " 








91 


25 " 










3 


4 « 








164 


26 " 










2 


5 " 








84 


27 " 










4 


6 " 








75 


28 " 










5 


7 " 








66 


29 " 










7 


8 " 








74 


30 " 










1 


9 " 








65 


31 " 










1 


10 " " . 








60 


32 " 










2 


11 " " . 








46 


33 " 










1 


12 " " . 








20 


34 " 










1 


13 " " . 








19 


35 " 










4 


14 " " . 








17 


36 " 













15 " " . 








12 


37 " 










2 


16 " " . 








10 


38 " 












17 " 








20 


39 " 












18 " 








8 


40 " 












19 " " . 








8 


41 " 












20 " " . 








8 


50 " 












21 " " . 








12 





22 '« " . 








13 


1000 


Males . 








512 


Right 485 


Females 








488 


Left . 










515 



Symptoms. The general characteristics of tuberculosis have 
been described in the chapters on Pott's disease and hip disease. 
In the description of these affections, however, but little stress 
was laid on local sensitiveness and local swelling, because the 
diseased parts lie at a distance from the surface and are concealed 
by the muscles and other tissues. At the knee, on the other 
hand, the joint is superficial, and even slight effusion changes, 
to a perceptible degree, its contour. If the disease is progres- 
sive sensitiveness to pressure, elevation of the local temperature, 
and infiltration or thickening of the tissues are usually present. 

Even when the patients are seen at a comparatively early stage 
in the course of the disease the history of the affection will almost 
always show that it is chronic and progressive in character. The 
importance of establishing this fact has been mentioned in the 
consideration of hip disease, and it may be stated again that a 
chronic painful disease of a single joint, accompanied by a ten- 
dency to deformity, is, in childhood, almost always tuberculous 
in character. 

The symptoms of tuberculous disease may be classified as 
limp, pain, local heat, sensitiveness and swelling, muscular spasm 
and limitation of motion, distortion and atrophy. 

On physical examination one will note the character of the 
limp and the slight flexion of the limb that usually accompanies 
it. The joint is, as a rule, somewhat enlarged, and the normal 



TUBERCULOUS DISEASE OF THE KNEE-JOINT. 403 

depressions about the patella and the projection of the component 
bones are less accentuated than on the opposite side. There is 
usually slight local elevation of temperature and sensitiveness to 
pressure, varying in degree with the character of the disease. 
In certain cases a degree of effusion is present, sufficient to be 
classed as synovitis, but in most instances the swelling is due, in 
great part, to the hyperemia and thickening of the synovial 

Fig. 247. 




Acute tuberculous arthritis of the knee. 



membrane and the capsule, which gives the sensation of elastic 
resistance rather than of actual fluctuation, 

The most important diagnostic sign is limitation of the range 
of motion caused by muscular spasm. The normal range is from 
complete extension, 180 degrees, to a degree of flexion, limited by 
the apposition of the calf and the posterior surface of the thigh. 
Even in the early stage of disease slight limitation of complete 



404 ORTHOPEDIC SURGER Y. 

extension is present, due to reflex muscular spasm, and usually a 
corresponding limitation of the complete flexion. On sudden 
movements the characteristic reflex contraction of the muscles is 
apparent. In most cases this limitation of motion and consequent 
flexion deformity is well marked on the first examination. 
Atrophy of the muscles of the thigh and calf, dependent upon 
the duration of the disease and upon the interference with func- 
tion, is present, and this atrophy is more noticeable because of 
the enlargement of the knee. 

In certain cases, more often seen in infancy and early child- 
hood, the symptoms are more acute and the progress of the 
disease is so rapid that it may simulate an infectious epiphysitis 
(Fig. 247). 

In another type, apparently a primary disease of the synovial 
membrane, more common in adults, the early symptoms are 
very similar to those of simple chronic synovitis. The joint is 
swollen by a distention of the capsule, pain is not troublesome 
except on jars or sudden twists of the limb, and muscular spasm 
and limitation of motion are evident only after a careful exam- 
ination. In this class, months or years may pass before the 
symptoms become as disabling as in the osteal type of the disease. 

Primary and Secondary Distortions of Knee-joint Disease. At the 
hip-joint, in which the range of motion is extensive, the deform- 
ities resulting from disease are somewhat complex, causing, for 
example, apparent shortening or lengthening, according as the 
limb is adducted or abducted. But the movements that the 
knee-joint permits are much simpler, and the primary distortion 
is simply flexion. Complete extension of the limb, the limit of 
normal motion in that direction, brings the joint surfaces into 
close apposition ; the ligaments are then tense and no lateral 
motion is permitted. This is the attitude in which the greatest 
efficiency of the limb for weight bearing is assured. When the 
ability of the knee for carrying out its normal weight-bearing 
function is lessened by disease which makes the parts sensitive 
to pressure and strain, the range of extension is lessened and the 
limb is persistently flexed to a greater or less degree, correspond- 
ing to the sensitiveness of the joint. The agents that adapt the 
limb to the habitual attitudes are the muscles under the control of 
the nervous system. In this sense the primary distortions are 
due to muscular action, but it is certainly not true that these 
muscles antagonize one another, and that the stronger over- 
coming the weaker cause the deformity, since the extensors at 



TUBERCULOUS DISEASE OF THE KNEE-JOINT. 405 



Fig. 248. 



this joint are stronger than the flexors, and since flexion is the 
primary deformity at every joint which is diseased without regard 
to the relative strength of the opposing muscular groups. 

In disease at the knee-joint, as at other joints, the extremes of 
motion in every direction that the joint permits are limited by 
muscular spasm, but limitation 
of extension, which is so essential 
to normal use, is at once evident, 
while limitation of flexion, the 
extreme of which is unessen- 
tial, is only apparent on examina- 
tion, and it may be absent even. 
Flexion is, then, the primary dis- 
tortion at the knee, and other 
deformities may be classed as 
secondary. 

Secondary Deformities. Of these 
the most common is outward 
rotation of the tibia upon the 
femur. When the limb is fully 
extended there is no lateral mo- 
tion at the knee, but when it is 
flexed lateral motion is possible, 
and in the attitude of flexion 
the traction of the biceps upon 
the head of the fibula tends to 
rotate it upon the femur. This 
deformity is also favored by the 
use of the limb in the attitude 

of outward rotation, which is always assumed when the weakness 
or stiffness of the knee-joint is present, and by the secondary 
knofk-knee that often accompanies the disease. 

Subluxation or backward displacement of the tibia upon tin- 
femur is another secondary deformity. When tin- leg is flexed 
upon the thigh the articulating surface ( >f the tibia .L r li<l« a back- 
ward upon the condyles of the femur. Here it becomes fixed by 
muscular contraction, and later by the secondary changes within 
the joint If muscular spasm be extreme this alone mighi 
the subluxation, but there are other factors ; one is the destruc- 
tive action of the disease, which is usually most marked af the 
point at which the bones are in contact, and the other is 
•verage exerted upon the joint. This is exen >y the 



1 





Tuberculous disease of the knee in an 
adult. The synovial type. 



406 



ORTHOPEDIC SURGERY. 



increase of the displacement that is often observed when an 
attempt is made to straighten the limb by force, against the 
resistance offered by the contracted tissues on the flexor aspect. 
The same leverage, in slighter degree, is exerted when the weight 



Fig. 249. 




Untreated disease of the knee-joint involving the shaft of the femur, illustrating the 
hypertrophy of the condyles of the femur, the subluxation and outward rotation of the 
tibia, the atrophy and the characteristic deformity. 



of the distorted limb is supported on the heel in the recumbent 
posture, or when the limb is extended in the act of walking, or if 
the upper extremity of the tibia is not supported during the 
period of treatment by apparatus (Fig. 246). 



TUBERCULOUS DISEASE OF THE KNEE-JOINT. 407 

Knock-knee (genii valgum) is another secondary deformity. 
This is explained in certain instances by the hypertrophy of the 
internal condyle caused by disease, but it is induced more directly 
by the use of the flexed and somewhat disabled limb id the pas- 
sive attitude of outward rotation. Genu varum is uncommon, 
and it is usually the result of the destruction of a part of the 
internal condyle of the femur or of the tibia, or of irregular 
epiphyseal growth. 

The character and the relative frequency of the deformities arc 
indicated by the statistics of KoenigV clinic, of 150 cases of knee- 
joint disease treated by arthrectomy, 128 of these being in children. 
In 94 cases flexion was present ; in 50, from a slight degree to 
135 degrees ; in 16, from 135 degrees to 90 ; in 28, to a righl 
angle or less. Together with the flexion were combined other 
deformities as follows : Genu valgum in 60 cases ; moderate in 
42; extreme in 18. Genu varum in 1 case. Subluxation of 
the tibia in 20 cases. Outward rotation of the tibia in 10 cases. 

As has been stated, the primary deformity of knee disease is 
simple flexion. If the disease is of an acute type this flexion 
increases rapidly. If it is subacute in character, and especially 
if the clinical signs indicate that the disease is primarily of the 
synovial membrane, the progress of the deformity is slow. In 
ordinary cases secondary deformities appear at a later time and 
especially when the disease has reached the destructive stage ; 
and they are most marked inpatients who have persistently used 
the deformed limb without protection. 

Actual Shortening and Actual Lengthening. Retardation of 
growth is, of course, not an early symptom of disease; in fact, 
actual lengthening of the limb, due to the irritative effect of the 
disease upon the epiphyseal cartilage of the femur or of the tibia. 
is common. This lengthening, sometimes to the extent of an 
inch or even more, may persist throughout the entire course of 
treatment, but after the cure of the disease a corresponding 
retardation of growth that will more than equalize the Length <»f 
the limbs, may be expected. When the disease is of the destruc- 
tive type the ultimate shortening may be considerable; two or 
more inches is not unusual. 

Leusden, 2 in 33 cases under treatment in the clinic at I 

tiii_r.?i. 1896-1898, found slight shortenting in •_!, equality "f 
Length in 18, lengthening of the femur on the diseased -id.- in 13. 

1 Loc. cit. - Deutsche ZeffA f. Chlr., B d L 



408 ORTHOPEDIC SURGER Y. 

In one hundred and sixteen cases of tuberculous disease of the 
knee the limbs were measured by Berry and Gibney 1 with refer- 
ence to this point. In 72 of these there was actual lengthening 
of the femur, from which in may be inferred that in at least 
62 per cent, of the cases examined the primary disease was of 
the femur. 

In 17 y A inch. 

"34 % " 

"15 % " ' 

"6 1 " 

72 = 62 per cent. 

H. L. Taylor, 2 from an examination of 40 cases of tuberculous 
disease of the knee, concludes that the limb is almost always 
longer in the first two years of the disease, usually longer during 
the second two years, but usually shorter when the period of 
growth is completed. The lengthening is in most instances of 
the femur. 

Diagnosis. Tuberculous disease is a local destructive process 
that is, as a rule, confined to a single joint. This is an important 
point in the differential diagnosis from general or constitutional 
affections like rheumatism, rheumatoid arthritis, and the like, in 
which several joints are involved. The following affections may 
be considered in differential diagnosis. 

Injury of the Knee. Strains of the knee in childhood are often 
followed by limp and persistent flexion and pain on motion. In 
such cases the onset is sudden and the symptoms usually disap- 
pear quickly under treatment. Synovitis of traumatic origin is 
usually indicative of a more severe injury. When synovitis per- 
sists the diagnosis may be doubtful because tuberculous infection 
may have followed the original injury. This emphasizes the 
importance of the careful treatment and continued observation of 
injuries of this class, especially in weakly children. 

Synovitis. Chronic synovitis of doubtful origin, which shows 
no tendency toward recovery, is usually tuberculous in character. 

Haemophilia. Effusion of blood into the knee-joint may cause 
inflammatory symptoms during the stage of absorption and 
organization of the clot that resemble those of disease. The 
sudden onset and the personal history of the patient, who may 
be known as a bleeder, will explain the symptoms. (See page 
283.) 

1 American Journal of the Medical Sciences, October, 1893. 

s Transactions American Orthopedic Association, 1901, vol. xiv. 



TUBERCULOUS DISEASE OF THE KNEE-JOINT. 409 

Infectious Arthritis — Acute Epiphysitis. This is of sudden 
onset, attended by the constitutional and local symptoms of acute 
infection. 

Rheumatism. This, in early childhood, may be confined to a 
single joint, but it is of sudden onset, it is usually accompanied 
by constitutional disturbance, and after a time other joints become 
involved. 

Rheumatoid Arthritis — Osteoarthritis. Diseases of this char- 
acter, of the monarticular form, are more common in adult life. 
The symptoms are rather of the rheumatic than of the tuber- 
culons type. 

Charcot's Disease. Charcot's disease of the knee-joint is char- 
acterized by sudden effusion, by rapid destruction of the joint, 
and consequently by weakness and deformity ; but pain is usually 
very slight and muscular spasm is absent. The diagnosis of dis- 
ease of the spinal cord will explain the condition of the joint. 
(See page 284.) 

Sarcoma. Sarcoma, beginning in or near the epiphysis of the 
femur or of the tibia, may simulate tuberculous disease very 
closely. If the tumor is of the periosteal type, it usually forms 
a more localized and irregular swelling than could be accounted 
for by tuberculous disease. Central sarcoma may simulate tuber- 
culous disease also, but the progress of the tumor is more rapid. 
The clinical distinction between the two is that tuberculous dis- 
ease is very amenable to treatment as far as its symptoms are 
concerned, while the progress of sarcoma is but little influenced 
by treatment. It may be stated, however, that the X-ray is the 
only means of early diagnosis, the destruction of the substance 
of the bone about the tumor being much greater than that caused 
by the tuberculous process. 

Hysterical Joint. Some of the symptoms of disease may l»« 
simulated by hvsterical subjects, but there is always an absence 
of the positive physical signs that invariably accompany a 
destructive disease. These and other affections arc described at 
length in the following chapters. 

Treatment. The treatment of tuberculous disease <>f the knee 
in childhood is conservative, operative intervention being simply 
incidental to protective treatment. In adult life, on the other 
hand, the radical removal of the disease may be indicated :i- the 
primary measure. The reasons for this distinction an; obvious. 
In childhood the duration of treatment ie of DO particular impor- 
tance a - compared with the final functional result, bul in adull 



410 



ORTHOPEDIC SURGERY. 



life the shortening of the period of disability and the definite 
assurance of cure may be of far greater moment than the preser- 
vation of motion. 

In childhood, under favorable conditions, ultimate recovery, with 
fair functional use of the joint, may be anticipated; while a radical 
operation, although it may cure the patient in a shorter time, 
takes away the possibility of a cure with motion. In adult life a 
rigid limb is a strong, useful, if somewhat awkward support, but 
in childhood the removal of portions of the epiphyses and of the 
epiphyseal cartilages entails a progressive inequality in the limbs, 
due to loss of growth, and unless the limb is protected by mechan- 
ical means deformity is the rule, even though the disease has been 
thoroughly removed. Thus the treatment of routine is, in child- 
hood, at least, protection ; protection from the traumatism of 

Fig. 250. 




Extension and counter-extension in disease of the knee-joint. (Marsh.) 



motion, from the shock of impact with the ground, and from the 
pressure of muscular spasm and contraction. 

Mechanical treatment, which is so difficult at the hip, is com- 
paratively easy at the knee, and, as has been stated, the results 
are correspondingly better. At the hip-joint one of the most 
common causes of shortening and deformity is upward displace- 
ment of the femur upon the pelvis, but at the knee, if the limb is 
supported in the attitude of extension, the apposition of the broad 
surfaces of the femur and the tibia prevents displacement, while 
muscular spasm, a symptom whose intensity is in proportion to 
the degree of harmful motion that is permitted, is easily controlled 
by efficient splinting. 

Reduction of Deformity. The first step in treatment is the 
reduction of deformity that may be present, in order that the 
limb, at the beginning as well as throughout the entire course of 
treatment, may be in absolute normal position ; and as the chief 
function of the leg is to support weight the proper attitude is 



TUBERCULOUS DISEASE OF THE KNEE-JOINT. 411 

complete extension. Whatever motion the patient retains will 
then be about the point of greatest usefulness. In the cases in 
which an opportunity for reasonably early treatment is offered 
the only deformity is flexion, induced by muscular contraction, 
although if it has persisted for some time secondary retraction of 
the muscles may be present. In this class of cases the >pa>m, 
and consequently the deformity, may be readily overcome by 
placing the joint at rest. 

Fig. 251. 




Tuberculous disease of the knee in an adult, with the form of Billroth iplinl 
at the Hospital for Raptured and Crippled. 

The Plaster Bandage. The most efficient splint for this purpose 
is a close-fitting plaster bandage, applied from the groin to the 
ankle, or, better, to include tic foot, in order to prevent oedema 
of the unsupported parr, which is common after the first dressing 
and until the circulation of the limb has become adapted to the 
new conditions. In the application of the bandage the bony 
prominences of the knee and anil" are protected by cotton. A 
canton-flannel bandage ; - then applied smoothly, and directly 
upon this the light plaster bandage. A- the second application, 



412 



ORTHOPEDIC SURGERY. 



at the end of a week, the subsidence of the spasm will permit the 
straightening of the limb. In cases of longer standing several 
successive applications of the bandage may be required, together 
with manual extension during the application ; or an anaesthetic may 
be administered. Under anesthesia the muscular spasm relaxes 
and deformity, even of some standing, may be reduced by traction 
and by slight leverage, the head of the tibia being supported and 
drawn forward by the hands as the deformity is gently reduced. 

Traction. Deformity may be reduced also by traction with 
the weight and pulley, the leg being supported so that no direct 
leverage is exerted at the seat of the disease (Fig. 250). 

Forcible Correction by Reverse Leverage. In the more resistant 
cases, especially if accompanied by subluxation, the following 
method may be employed : The patient is anaesthetized and is 
placed face downward on a table, the feet projecting over its end. 



Fig. 252. 





-^"* ^^^^K Q-' mk^^^^^^^^^^mk. . .- 


fSI 








** 




i 





Illustrating the method of supporting the body and fixing the tibia before straightening 
the limb. The folded sheet indicates the degree of subluxation present. In resistant cases 
of this type an assistant applies the pressure on the thigh. 



The body of the patient is then elevated by means of pillows to 
conform to the deformity — that is, the thigh of the affected limb 
is raised sufficiently to allow the tibia to lie evenly upon its an- 
terior border on the table. The operator with one hand holds 
the head of the tibia firmly against the table and with the other 
massages the contracted tissues of the popliteal region, gradually 
exerting more downward pressure on the thigh, but never to the 
extent to lift the tibia from the table ; thus, further subluxation 
is impossible. As the contraction gives way the pillows are 
removed. Usually the deformity may be reduced at one sitting, 
but if it is very resistant complete correction is not attempted. At 
the conclusion of the operation adhesive plaster straps for traction 
and a close-fitting plaster bandage are applied (Fig. 252). 



Fig. 258. 



TUBERCULOUS DISEASE OF THE KNEE JOINT. \\ ;] 

Rest in bed with traction is enforced for a time, and the ordi- 
nary brace is then employed. This is, in the author's experience, 
the most effective and satisfactory method for reducing deformity. 
If the contraction is of long standing preliminary division of the 
flexor tendons may be advisable, but this is not usually necessary. 1 

The Billroth Splint. The Billroth splint, as modified by Still- 
man, is an effective appliance for overcoming resistant deform it v. 
A thick pad of felt is placed over the 
upper surface of the condyles of the 
femur and a thinner pad in the 
popliteal region over the upper bor- 
der of the tibia. Other points that 
may be subjected to pressure are 
similarly protected, especially the 
dorsum of the foot and the perineum. 
A plaster bandage is then applied 
from the groin to the toes, made 
especially thick and strong in the 
popliteal region. On either side of 
the knee two curved, slotted steel 
bars attached to expanded tin splints 
and joined to one another by an 
adjustable bolt are incorporated in 
it (Fig. 251). AVhen the bandage 
hardens it is completely divided into 
two parts by a circular cut about the 
knee, and the bolts in the slots are f ™* B ; ad J° 

for the correction of flexion deformity 

so adjusted as to form a hinged splint, and subluxation at the knee. Counter- 

. _ . . i pressure is applied over the lower ex- 

the centre of motion being somewhat tremity of the femur. subluxation ii 

qbr.vP nnrl in front of the knep-inint P revenled during the forcible 

aoove ana in irontor tne Knee joint. tiou bymean> ot lhe ^ a] 
When the limb is slightly extended beneath the head ofth.tii.iaj> 

. . . /» i l • * i it is drawn forward. 

the position of the hinges has a 

tendency to lift the tibia and to separate it from the femur. 
r l 'hi- Btraightening opens the cut in the popliteal region, which 
is held open by a wedge of cork. In this manner, by the in- 
sertion of larger wedges, the limb is gradually straightened from 
day to day until the deformity is overcome, or until a Dew band- 
a required. If the pressure on the front of the femur, 
when the leverage is exerted, becomes painful, a part of the pad- 
ding is removed. 




Whitman. American Journal of the Medical 8 



414 



ORTHOPEDIC SURGERY. 



In the treatment of older subjects greater force may be em- 
ployed by means of osteoclasts. One of the best, machines of this 
type is the Bradford-Goldthwait genuclast (Fig. 253). The more 
violent methods should not be employed during the active stages 
of the disease ; and whenever considerable force is required in 
young subjects the possibility of separating the epiphysis of the 
femur, forcing it backward, and thus pressing upon the popliteal 
vessels, should be borne in mind. 

Mechanical Treatment. The most efficient mechanical appliance 
for the treatment of tuberculous disease at the knee is the Thomas 



Fig. 254. 



Fig. 255. 




The Thomas knee-splint, showing the 
inner bar B placed farther to the front 
than the outer bar C ; A is the lowest 
part of the'ring ; upon this rests the tuber- 
osity of the ischium. 



The ring of the Thomas knee-splint after 
padding. (Ridlon.) 



knee brace. This consists of two lateral uprights which support 
the limb on either side, terminating below the foot in a crossbar 
shod with leather or rubber, which serves as a stilt, and above in 
a ring that fits the upper extremity of the thigh, and supports 
the weight of the body. The brace is made of iron wire from 
three-sixteenths to three-eighths of an inch in thickness. The 
ring is of an irregular ovoid shape, flattened in front, expanded 



TUBERCULOUS DISEASE OF THE KNEE-JOINT. 415 

behind, and wider on the inner than on the outer side (Fig. 254). 
This ring is welded to the uprights at a lateral and anteropos- 
terior inclination. The lateral inclination forms an anole with 

o 

the inner bar of 135 degrees (Fig. 25(3), the anteroposterior 
inclination forms an anterior angle of 145 degrees (Fig. 255) 
with the same upright, which is set upon the ring at a point 
slightly in advance of its fellow. The objects of the shape of 
the ring and of its inclination are these : its anterior part is flat, 
because the surface of the groin is flat ; its posterior segment 
is expanded to accommodate the thickness of the buttock ; the 



Fig. 256. 



Fig. 257. 





Showing the front of the ring of the 
Thomas knee-splint. 



Showing the back of the ring of the 
Thomas knee-splint. (Ridlon.) 



anteroposterior inclination allows the ring to rest comfortably 
beneath the tuberosity of the ischium. The lateral inclination 
which follows the line of Poupart's ligament is made necessary 
by the greater length of the outer bar, which, in order to assure 
better support and less pressure, rises above the level of the tro- 
chanter major. 

The ring is made somewhat larger than the thigh to allow for 

padding with felt. This should be thicker on the inner and 

ior surface, where the weight La borne, than on the anterior 

and outer part. The padded ring i- then smoothly covered 

with basil leather. A- used at the Hospital for Ruptured and 



416 



ORTHOPEDIC SURGERY. 



Fig. 258. 



( rippled, the brace is made from two to three inches longer than 
the leg, to serve as a stilt like the hip splint. To the foot-piece 
two straps are attached on either side to provide for traction on 
the limb and to hold the brace securely in its place. A band of 
leather is drawn between the bars at the upper third and another 

at the lower third of the brace to 
serve as supports for the thigh and 
calf. Adhesive plasters, reaching 
from the knee to the ankle, pro- 
vided with buckles above the mal- 
leoli, having been applied, the ring 
is pushed firmly against the per- 
ineum and is held in position by 
buckling the straps to the traction 
plasters with as much tension as 
the comfort of the patient will per- 
mit. The thigh and leg supports 
should fit the parts perfectly ; the 
knee is then fixed in its place by 
a bandage drawn tightly about it 
and the lateral bars. Ankle and 
heel straps complete the adjust- 
ment (Fig. 258). 

In cases in which the joint is sen- 
sitive and in which there is a ten- 
Si dency to deformity the entire limb 
H is in addition enclosed in a light 
-\ plaster bandage, so-called " skin 
J\\ fitting/ 5 applied directly upon a 
I H flannel bandage. 

|gg If the brace is attached by means 

of the adhesive plaster straps, a 
certain amoimt of traction is as- 
sured, together with additional 
accuracy of adjustment; and by the traction and by the direct 
pressure on the knee the slighter degrees of deformity may be 
reduced without discomfort. In acute cases preliminary rest in 
bed is advisable, and crutches may be employed in the early stages 
of ambulatory treatment. But during the greater part of the 
is • the splint serves as a perineal crutch, and by the use of 
slight corrective force when the plaster bandages are applied, or 
by traction at times toward one or the other upright, lateral dis- 




The Thomas knee-brace. 



T VEER C UL US DISEA SE OF THE KNEE-JOINT. 417 

tortiou of the linib may be corrected during the course of treat- 
ment. This brace may be used in the treatment of very vounfj 
children if it is carefully fitted and if the parts are kept clean and 
dry, and it is an effective brace for all ages, and for all conditions 
of disease. 

The Caliper Brace. The traction may be discarded and the 
brace may be held in position by a shoulder band, or it may be 
used as a so-called caliper splint. In this form it was almost 
exclusively employed by Mr. Thomas in his later practice and at 
the present time by Eidlon, 1 the long brace being used simply for 
a bed splint. As a caliper brace the two bars are cut off, turned 
directly inward at a right angle, and are inserted into a steel 
tube, which is passed through the heel of the shoe. The bars are 
made slightly longer than the limb, so that the patient's heel is 
lifted nearly an inch from the inside of the shoe when walking ; 
thus, the jar of impact with the ground is prevented. The brace 
is fixed in position by a leather band beneath the knee and another 
beneath the calf, and the limb is held extended by pressure pads 
applied to the thigh and leg, as illustrated (Fig. 259). Ridlon 
uses the brace to reduce deformity by direct pressure backward on 
the knee by means of bandages, opiates being given to relieve 
pain. 

Other braces may be employed, for example, the traction hip 
splint, but as the Thomas brace answers every requirement it seems 
unnecessary to describe others in this connection. 

Accessory Treatment. The accessories to protective treatment, 
which, of course, includes the proper attention of the general con- 
dition of the patient, are local applications, injections, and venous 
stasis. They are classed as accessories because none of them is 
itial to successful treatment. 

The local application of cautery, applied at intervals of a week 
or less, may add to the comfort of the patient and stimulate the 
reparative processes. The X-ray appears to act in a somewhat 
similar manner; it relieves pain, and in most instances the infil- 
tration of the tissues becomes less marked. 

Ichthvol ointment of a strength of about 40 per cent, certainly 
relieves pain and local congestion in certain instance-. Firm 
compression by means of a flannel bandar*' and by tin- adhesive 
plaster -trapping is of value, especially in the infiltrating, 4 - b 
type of disease. 

Transactions American Orthopedic Association, vol. vi. 
27 



418 



OR THOPEDIC SURGER Y. 



Fig. 259. 



K 



Chf 



The knee is the joint into which injections of iodoform emulsion 
may be made most easily. Such injections are more likely to be 
of service in the synovial than in the osteal 
type of disease. About 10 c.c. of a 10 per 
cent, emulsion of iodoform in sweet oil may 
be injected through a trocar into the dis- 
tended capsule at intervals of several weeks. 
It is then distributed by gentle massage. It 
may aid the reparative processes by an irri- 
tative stimulation, but it apparently exerts 
no very direct influence on the tuberculous 
process. 

Bier's treatment by passive congestion 
may be easily applied to the joint. The 
limb up to the joint is firmly bandaged by 
a flannel bandage. A rubber band is then 
applied immediately above the joint with 
sufficient tension to retard the return of the 
venous blood. The joint then becomes 
swollen and congested. The congestion is 
at first used for an hour or more at a time 
once or twice daily. Later it may be ap- 
plied continuously. Passive congestion ap- 
parently increases the stability of the granu- 
lation tissue and its further transformation 
to fibrous tissue. The method should not 
be employed during the acute phases of the 
disease. (See page 259.) 

Treatment during Convalescence. During 
the active stage of the disease the brace must 
be worn day and night ; during the stage of 
recovery it may be removed at night to allow 
for motion at the knee, and later a form of 
walking brace (Fig. 176) that will allow a 
limited motion at the knee may be of service ; 
but this is not an essential in treatment. If 
slight knock-knee remains after recovery, 
it may be overcome by the use of a Thomas 
knock-knee brace, which will also serve as a 
protection to the weak joint. 
The indications of cure have been discussed under hip disease. 
In brief, when sufficient time has elapsed to permit of natural 



The caliper splint. E, the 
ring around the upper part 
of the thigh. A, pad for 
backward pressure. B, 
bandage. C, bandage. F, 
leather sling for support at 
the back of the limb. D, a 
strip of bandage fastening 
together the pressure pads 
to prevent slipping and con- 
sequent loss of pressure. 
(Ridlon and Jones.) 



TUBERCULOUS DISEASE OF THE KNEE-JOINT. 419 

cure ; when there have been no symptoms of active disease for 
months ; when muscular spasm has disappeared, one may tenta- 
tively remove the brace in the manner described. But any 
symptom of disease, and particularly increasing limitation of the 
range of motion, or a tendency toward deformity, indicates the 
necessity for continued protection. 

If anchylosis is present supervision and occasional treatment 
will be required during the period of growth in order to prevent 
deformity. 

Extra -articular Disease and Operative Intervention. In certain 
cases, especially iu young children, the disease about the epi- 
physeal cartilage of the femur or of the tibia may find its way to 
the exterior of the bone before it invades the joint. This fortu- 
nate course is indicated by local sensitiveness and swelling over 
one of the condyles of the femur or about the head of the tibia. 
In such instances the thorough removal of the disease is indi- 
cated, or if a Koentgen picture shows that the disease is accessible, 
even though it is not immediately below the surface, an explora- 
tory operation may be advisable. An incision is made, usually 
over the internal condyle of the femur. The periosteum is raised 
and a portion of the cortex is removed in order to expose the 
spongy bone on either side of the epiphyseal cartilage. 

In many instances an area of softening will be found. This 
must be thoroughly removed. The cavity may be treated with 
pure carbolic acid or the cautery, or filled with iodoform emulsion 
or paraffin, and the wound is then closed. In favorable cases 
prompt operative intervention may cut short the course of the 
disease. 

Abscess. Abscess is present as a complication in about one- 
third of the cases that have received efficient protection, and in a 
larger percentage of those in which treatment has been neglected. 

It was present in 51 per cent, of Koenig's cases 1 and in 47 per 
cent, of three hundred final results reported by Gibney. 2 At the 
knee, as at other joints, the infected abscess is the most dangerous 
complication of the disease, as is illustrated by Koenig's statistics : 

Death-rate in cases without abscess 25 per cent. 

" with abscess 46 " 

Although in many instances abscess indicates an extensive and 
destructive disease of the bone, yet the exhausting suppuration 
that is an indirect cause of death is suppuration from infected 

1 Loc. cit. - American Journal of the Medical Sciences, October, 1888. 



420 ORTHOPEDIC SURGEB Y. 

areas in the thigh and leg, which may have little direct relation 
to the extent of the original disease. It should be the aim in 
treatment to prevent this burrowing of fluid after the capsule has 
been perforated, and to prevent overdistention of the capsule even 
in order to lessen the macerating effect of the tuberculous fluid 
upon the cartilages. When the fluid within the joint is of con- 
siderable amount, and when it is increasing in quantity, it may 
be removed by aspiration, or a better procedure is to incise the 
capsule. This will allow a thorough removal of its fluid and 
solid contents, after which the opening may be closed with 
sutures. 

Tuberculous abscess which has perforated the capsule may be 
treated in the same manner, or it may be drained subsequently, 
according to the indications. Unless the abscess is infected 
careful bandaging of the thigh and leg should prevent burrowing. 

Synovial Tuberculosis. In the forms of synovial tuberculosis 
that resemble chronic synovitis the fluid, if the quantity is large, 
may be evacuated by an incision in the capsule which will allow 
for exploration and for removal of the fibrinous masses that are 
often present. Afterward the interior of the joint may be treated 
with an application of a strong solution of chloride of zinc or pure 
carbolic acid. This sets up an active reaction which causes adhe- 
sions within the capsule, and exerts a favorable influence on the 
course of the disease. A protective brace should be worn to 
guard the joint from sudden twists and strains and to limit the 
range of motion within the painless arc. The adhesive plaster 
strapping may be employed in cases of this type with great advan- 
tage. Such a brace is shown in Fig. 176. The injection of 
iodoform emulsion should be of particular advantage in the treat- 
ment of this form of disease. Theoretically, its use should 
modify the infectious quality of the tuberculous fluid and lessen 
the danger of infection with pyogenic germs, and on this ground, 
rather than because it actually shortens the course of the disease, 
it may be recommended. 

Arthrectomy. When, as in exceptional cases, the disease is 
progressive and shows no tendency toward recovery, and particu- 
larly if an infected abscess communicating with the joint makes 
efficient drainage difficult, the operation of arthrectomy may be 
indicated. 

An Esmarch bandage having been applied, the joint is thor- 
oughly exposed by a curved anterior incision passing above or 
below or through the patella, and all the diseased tissue is re- 



TUBERCULOUS DISEASE OF THE KXEE-JOIXT. 421 

moved ; that in the soft parts is cut away, and foci in the bone 
are excavated with the chisel and scoop. If infection be present 
the joint may be packed with gauze, the leg being fixed in the 
position of flexion ; but in other instances the wound is closed 
with or without drainage as may seem advisable. In a large 
proportion of cases primary healing may be obtained. By the 
procedure oue may hope to cure the disease, but in all but excep- 
tional cases the functional result will be anchylosis. The opera- 
tion has the advantage over excision in that less bone is removed, 
and that the epiphyseal cartilages, in part, at least, remain ; thus, 
the immediate as well as the ultimate shortening is less than after 
excision. 

Results of Akthrectomy. The direct death-rate of the 
operation is small. In 150 cases reported by Koenig but 3 deaths 
were attributable to the operation itself. The final results in 114 
of these cases, in which the operation was performed in childhood, 
were as follows : 

Patients cured and living 90 

Cured of the local disease, but not living at the time of 

the investigation 10 

Practically cured, insignificant fistulse remaining . . 2 

102 = 89.5 per ct. 

LiviDg, not cured 5 

Deaths before the cure of the local disease .... 7 

12 = 10.5 per ct. 

Thus in 89 per cent, of the cases the operation was successful 
as far as the cure of the local disease was concerned. In 75 per 
cent of the successful cases immediate cure was attained ; in 25 
per cent, fistulse persisted for a longer or shorter time. In 10 
cases some motion was retained, but in the others anchylosis fol- 
lowed the operation. In about 70 per cent, of the cases the limb 
was practically straight ; in 30 per cent, it was distorted. This 
shows the necessity of continued supervision and in many in- 
stances of protective treatment during the growing period in all 
- in which anchylosis is present from whatever cause. 

In forty-eight cases in which the operation had been performed 
before the tenth year, and in which the limbs were .straight, the 
influence of the operation on the growth waa investigated. 

Years elapsed A verage shorUnlnn 
■^ of cases. since operation. in cm. 

6 2 1 

5 a i.<> 

4 4 1 

3 5 2 

19 2 

11 



422 



ORTHOPEDIC SURGERY. 



Fig- 260. 



Those measurements indicate that the shortening is not likely to 
be very great as a result of the operation, certainly very much less 
than after complete or even partial excision performed at the 
same age. 

Excision. Excision of the joint in childhood has been practi- 
cally abandoned, because of the great shortening that follows 
complete removal of the epiphyses, and because so-called partial 
excision — that is, the removal of the thin sections of bone from 

the surfaces of the femur and 
tibia, leaving the cartilages 
— is usually an unnecessary 
operation, in the sense that 
disease that might be cured 
by this procedure might have 
been cured by conservative 
methods. 

Early excision in adult 
cases is often indicated be- 
cause it will assure a cure of 
the disease in a short time, 
whereas mechanical treat- 
ment will require years of 
disability with no certain 
prospect of absolute cure at 
the end of the period. If, 
therefore, the disease has pro- 
gressed sufficiently to indicate 
that the natural cure would 
result in anchylosis, or if 
the time required for natural 
cure is of importance to the 
patient, early excision may 
be advised in the case of the adult or adolescent whose growth 
is nearly completed. 

The operation is performed under the Esmarch bandage, and 
the joint is exposed by the anterior incision, as in the operation of 
arthrectomy. All the diseased tissues are cut away and sections 
of the bones, parallel to the articular surfaces, are removed, 
sufficient in depth to include all the diseased area. If the sec- 
tions are so made as to allow the bones to be brought into close 
apposition, sutures through the periosteum will hold them in 
position, without niils or wiring. The vessels having been 




Deformity and shortening resulting from ex- 
cision of the knee in childhood. 



TUBERCULOUS DISEASE OF THE KXEE-JOIXT. 423 

ligated, the wound may be closed with or without drainage, as 
may be indicated by the character of the disease, a plaster-of- 
Paris dressing is applied, and the limb is elevated. Mechanical 
support is of service in the after-treatment in lessening the 
discomfort and hastening the cure. 

Eesults of Excisiox. In Koenig's statistics of 300 ex- 
cisions, 6 deaths were due directly to the operation, and 23 others 
occurred during the course of the after-treatment — a total of 29 
(9.6 per cent.). 

In 23 instances amputation was afterward performed because 
of failure of the operation. The good results are classed by 
Koenig as 75 per cent., the bad as 25 per cent. In 193 cases 
the position of the limb in after years was investigated. It was 
straight in 175, distorted in 18, all but 1 of this latter group 
being in children. 

Amputation. This operation is indicated as a life-saving 
measure. "When the disease is so extensive as to require com- 
plete removal of the epiphyses in early childhood, amputation is 
the preferable operation, as the limb, aside from requiring con- 
stant protection to prevent deformity, will be so short as to be of 
little practical use. 

Operations for the Relief of Final Deformity. In the majority 
of the cases deformity can be rectified by one of the methods 
already described. If, however, there is bony anchylosis in an 
attitude of marked flexion the limb may be straightened by the 
removal of a sufficient wedge of bone from the joint. The de- 
formity may be remedied almost equally well by linear osteotomy 
of the femur just above the joint, and this operation is to be 
preferred in young subjects, as no bone is removed. 

Genu valgum may be corrected by a similar operation. (See 
( Osteotomy for Knock-knee.) 

Prognosis. The most important statistical evidence on the 
course and the outcome of tuberculous disease of the knee-joint 
in childhood has been presented by Gibney. The statistics com- 
pleted in 1892 were the result of an investigation of 499 cases 
treated during a period of twenty years, 1868-1887. In but 
300 of these could definite information be obtained. 1 

Eighty-seven per cent, of the cases were in children, and ~>\ 
per cent, of the patients were less than five year- of age at the 
inception of the disea-<\ 

] American Journal of the Medical Sciences, October, 1893. 



m 



OR TlloriWIC SUBGER Y. 



The cases were divided into three classes, according to the 
treatment that had been followed : 

1. The expectant treatment. In this class no apparatus was 
employed, or, if employed, it was inefficiently used. 

'2. The fixation treatment. In this class the joint was more 
or less efficiently splinted, but not protected from impact with 
the ground. 

3. The protective treatment. In this class the joint was both 
splinted and protected from jar, and the mechanical treatment 
was efficient. 

The results were classified as follows : 



Expectant . 
Fixation 
Protection . 



Total. 



71 
]90 



300 



Excisions. 



Amputations. 


Deaths. 


Under 
treatment. 


3 

1 



3 

35 
2 


9 
31 
11 


4 


40 


51 



Cured. 



51 
114 
26 



191 



Mortality. The total deaths in the 300 cases were 40 (13.3 
per cent.) ; 26 of these were from causes directly or indirectly 
connected with the disease (8.6 per cent.), viz. : 

Operative shock 1 

Prolonged suppuration 16 

Tuberculous meningitis 6 

Phthisis 3 

26 
Intercurrent diseases 14 

40 

Function. The functional results as regards motion in the 
cases in which conservative treatment was continued to the end, 
including the cases still under observation, 242 of 300, were as 
follows : 





Total. 


Motion retained. 


Anchylosed. 


Expectant 

Fixation 

Protection 


60 
145 
37 


44 or 7 per ct. 
113 " 77 
34 " 95 


16 

32 

3 




242 


191 or 79 per ct. 


51 



Of the 191 patients who retained a movable joint, 74 had 
had abscesses, 3 or more cicatrices being present in 39. 

As to the range of motion, in 74 it was from 45 degrees to 



TUBERCULOUS DISEASE OF THE KNEE-JOINT. 425 

normal and in 41 more than 90 degrees; thus 30 per cent, of the 
patients retained a fair range of motion. 

Deformity. In 51 cases anchylosis was present; in 16 of these 
the limb was practically straight, in 35 it was flexed more than 
30 degrees (69 per cent.). 

These statistics again illustrate the great tendency toward 
deformity, when during the growing period there is anchylosis at 
the knee from whatever cause. 

In the 191 cases in which motion was retained the limb was 
practically straight in 125 (65 per cent.). In 49 others the 
flexion was less than 25 degrees, and in but 16 could the 
deformity be classed as bad (8 per cent,). 

In 10 cases only did relapse occur after apparent cure. 

In but 16 of the 449 cases was there involvement of other 
joints while the patients were under observation (3.2 per cent.). 
In 8 of these the spine was involved, in 2 the hip, and in 6 
other joints. 

The influence of age upon the death-rate and the ultimate 
causes of death are illustrated by Koenig's statistics, the death- 
rate being much higher, at least in the cases in early childhood, 
than in this country. 

According to Koenig's statistics, the death-rate, direct and 
indirect, from disease of the knee-joint, was as follows : 

323 children ( 1 to 15 years of age), deaths . . 65 = 20 per cent. 

225 patients (16 " 30 " " ), " . . 61 = 24 

68 " (31 " 40 " " ), " . 30 = 44 

74 " more than 40 years of age " . .45 = 60 " 

Causes of Death. 

Deaths from causes not connected with the disease . 14 = 2 per cent. 

" following operations 18 = 2.5 " 

" caused by tuberculosis, 141 = 22.5 per cent, of all cases and 
80 per cent, of all the deaths. 

Tuberculosis of the knee 1 

" " lungs 94 

General tuberculosis 30 

Tuberculous meningitis 7 

Acute miliary tuberculosis 3 

Tuberculosis of other parts 6 

141 

It may be noted that 1*6 of the 40 deaths in Gibney's cases 
were due to prolonged suppuration, and that of 51 cases still 
under observation 26 had been treated for ten years or longer, 
and were still uncured. This indicates that in a larger propor- 
tion of the cases conservative methods should have been supple- 



426 ORTHOPEDIC SURGERY. 

mented by more radical treatment. Still, taken as a whole, the 
results, although the mechanical treatment was, in many instances, 
far fnmi efficient, are much better than any others that have been 
presented. 

General Conclusions. On this evidence the following^con- 
clusions seem to be justified. The death-rate in childhood from 
all causes should be less than 10 per cent. The duration of 
treatment is from two to five years. Recovery with a useful 
range of motion, when the diagnosis has been made at an early 
stage and when efficient mechanical treatment has been employed, 
may be predicted in oO per cent, of the cases. 

1 >ef ormity can always be prevented by treatment and by super- 
vision. Under favorable conditions radical operations are not 
often indicated, but when indicated they should not be delayed 
too long. Amputation of the limb should prevent death from 
prolonged suppuration. In a certain proportion of cases the 
disease may be cut short by early exploratory operations, for the 
removal of foci of disease in the bone before the joint has become 
involved. 

Although the benefits of protective treatment are as evident in 
disease of the adult as in childhood, yet early operation is often 
indicated in this class, because of the necessity for shortening the 
period of disability, and because excision assures a straight anpl 
useful limb. 



CHAPTER X. 

NON-TUBERCULOUS AFFECTIONS AND DEFORMITIES OF 
THE KNEE-JOINT. 

Strains and Injuries of the Knee in Childhood. 

Injury of the knee in childhood may cause local discomfort 
and persistent flexion of the leg, even when but little synovial 
effusion is present. In this class of cases the application of a 
plaster bandage, under sufficient traction to overcome the deform- 
ity, is of service in placing the part at rest and preventing further 
injury. The importance of treating promptly slight injuries of 
the joints in childhood, especially in the class of patients predis- 
posed to tuberculous infection, has been mentioned already in the 
consideration of hip disease. 

Muscular " cramp" a form of tetanic contraction, induced 
possibly by injur}', which fixes the limb in a flexed or extended 
position, is sometimes seen in children of a susceptible or nervous 
temperament. The treatment is similar to that of strains. 

Synovitis. 

Acute traumatic synovitis is properly treated, immediately after 
the injury, by splints, by elevation of the limb, by the application 
of ice-bags and the like ; but after the acute symptoms have sub- 
sided the absorption of the effused fluid is aided by functional 
use of the limb, if the joint is properly protected. One of the 
most efficient methods of treatment is that by means of the adhe- 
sive plaster strapping advocated by Cottrell and Gibney. The 
entire surface of the knee, except a narrow space in the popliteal 
region, is firmly strapped with overlapping layers of adhesive 
plaster, extending from the upper third of the leg to the middle 
third of the thigh ; and over this a flannel bandage is applied ; 
or if the leg is swollen, the entire limb should be firmly bandaged 
with clastic stockinette bandage, from the toes to the upper third 
of the thigh in addition (Fig. 267). The adhesive plaster serves 
a- a support which allows a certain degree of motion, sufficient to 
stimulate the circulation, and thus to hasten the restoration of 



42S 



ORTHOPEDIC SURGERY. 



the normal condition. If greater compression is desired, the 
entire joint may be covered with the adhesive plaster as suggested 
by Hoffmann. 1 A pad of cotton is placed in the popliteal space, 
a close-fitting stocking leg is drawn over the knee, and about 
this circular bands of plaster are drawn as tightly as the comfort 
of the patient will permit. The adhesive plaster strapping is 
renewed from time to time, as the swelling diminishes, and its 
use is continued until the symptoms have entirely disappeared. 

Chronic synovitis may be treated in a similar manner, although 
if the effusion is persistent the fluid may be removed by aspira- 
tion. If the ligaments are lax, a supporting brace may be 
required for a time (Fig. 176). Massage and exercises and static 
electricity are of service in the stage of recovery to restore the 
strength and activity of the supporting muscles. 

Infectious Arthritis. 

Suppurative arthritis of this as of other joints should be 
treated by free incisions, and efficient drainage should be assured. 
If this cannot be attained by ordinary methods the capsule should 
be widely opened and the patella divided by means of a trans- 
verse anterior incision. The interior of the joint may then be 
completely exposed by flexing the leg to an acute angle, as sug- 
gested by Mayo. Mechanical protection is usually required after 
the immediate symptoms are relieved. The subject is considered 
more at length elsewhere. (See Chapter VI.) 



Osteoarthritis. 

In this disease several joints are usually involved, but occasion- 
ally the affection may be confined to the knee. The early symp- 
toms are stiffness, discomfort, and pain more noticeable in damp 
weather, and often creaking sensations in the joint are appreciable 
to the patient. At intervals the symptoms may be more acute 
and the joint becomes hot and swollen ; as a rule, however, they 
are subacute in character. The progress of the affection is slow, 
the joint becomes somewhat enlarged and irregular in outline, the 
range of motion becomes more restricted, and flexion of the limb 
after a time persists. (See Rheumatoid Arthritis, page 274.) 

Treatment. The general and constitutional treatment does 
not require especial consideration here. Locally massage and 

1 New York Medical Journal, January 27, 1900. 



XOX-TUBEBC CLOUS AFFECTIOXS OF KXEE-JOIXT. 429 

the hot-air bath may add to the comfort of the patient and in- 
crease the mobility of the joint, in the early stage of the affection 
at least. Static electricity has been employed with advantage in 
certain cases. The application of the cautery and stimulating 
liniments are useful in relieving pain, and the support of a flannel 
bandage adds much to the comfort of the patient. In many 
instances a brace (Fig. 176) may be employed with advantage to 
lessen the strain upon the part. Operative removal of the hyper- 
trophied synovial membrane, loose bodies or irregular projections 
of bone that may interfere directly with movement, is sometimes 
of service. Excision is a final remedy in extreme cases. 

Prepatellar Bursitis. 

Synonym. Housemaid's knee. 

A chronic enlargement of the bursa lying over the patella and 
its ligament is common among those who have to kneel much 
of the time ; hence the popular name. Occasionally cases of acute 
bursitis, in which there is considerable effusion into the sac, are 
seen, and these are sometimes mistaken for synovitis of the knee. 

Treatment. In acute cases strapping the front of the knee 
with strips of adhesive plaster which will limit motion and pro- 
vide compression is an effective treatment. If the effusion is 
considerable it may be relieved by aspiration. In chronic cases 
cure can be attained only by the removal of the thickened sac. 

Pre tibial Bursitis. 

Beneath the ligamentum patellae, occupying the space between 
the tendon and the periosteum of the tibia, is the deep pretibial 
bursa. It is, according to the investigations of Lovett, 1 as wide 
or somewhat wider than the tendon ; its upper border is on a 
level with the joint, its lower border reaches to the tubercle of 
the tibia, and, being slightly longer on the outer than on the 
inner border, it is somewhat triangular in shape. It does not 
communicate with the knee-joint. 

Enlargement of this bursa is, as a rule, the result of injury, 
but, as bursitis elsewhere, it may be a complication of infectious 
diseases, rheumatism and the like. 

Symptoms. The symptoms are stiffness at the knee and pain 
on sudden movement, especially when strain is exerted on the 

] Boston City Hospital Reports, 8th series, 1897. 



430 ORTHOPEDIC SURGERY. 

tendon by complete flexion or extension of the leg as in active 
use. The tubercle of the tibia seems enlarged and is sensitive 
to pressure, and a swelling on either side of the ligament is 
usually evident. 

Treatment. The affection, if at all acute, may be treated by 
relieving the strain and pressure on the tendon, by fixation of 
the limb for a time in a plaster bandage or other form of splint. 
Later the adhesive plaster strapping will provide sufficient fixa- 
tion and pressure. The absorption of the fluid may be hastened 
by the application of the cautery. If the swelling is persistent, 
the fluid may be removed by aspiration or incision or removal of 
the sac. 

Enlargement of the Superficial Pretibial Bursa. 

A small bursa, lying upon the insertion of the ligamentum 
patellae, may become enlarged, causing an apparent hypertrophy 
of the tubercle of the tibia. It may be treated by strapping with 
adhesive plaster, and the prominent tubercle should be protected 
by some form of bunion plaster. 

Injury of the Tibial Tubercle. 

Osgood 1 has called attention to the fact that symptoms resem- 
bling those described may be caused by partial separation of the 
tubercle of the tibia. The treatment is primarily rest in the 
extended posture. 

Bursse and Cysts in the Popliteal Region. 

Simple inflammation of the bursa lying between the inner head 
of the gastrocnemius and the semimembranosus muscle may cause 
a fluctuating swelling on the inner side of the popliteal region. 
It may be treated by compression or by incision as may seem 
advisable. Cysts in the popliteal region usually communicate 
with the knee-joint and are complications of rheumatic or tuber- 
culous disease. They are of interest principally from the diag- 
nostic standpoint. 

Internal Derangement of the Knee-joint. (Hey.) 

The term internal derangement signifies sudden interference 
with the function of the joint which may be due to (a) loose 

1 Boston Medical and Surgical Journal, January 29, 1903. 



NON-TUBERCULOUS AFFECTIONS OF KNEE-JOINT. 431 

bodies in the joint • (b) displacement or fracture of a semilunar 
cartilage ; (c) other injury. 1 

Loose Bodies in the Knee-joint. Loose bodies in the knee- 
joint may be composed of portions of fibrin, fragments of synovial 
membrane, or bits of cartilage or bone, and the like. In certain 
forms of synovial tuberculosis and osteoarthritis these loose bodies 
may be present in large numbers, but from the therapeutical 
standpoint the importaut cases are those in which the joint is 
otherwise normal. In this class the foreign body is sometimes 
detected by the patient as a smooth, movable object on one or the 
other side of the patella ; but in many instances the first sign of 
its presence is interference with the function of the joint. After 
a sudden movement or when the knee has been flexed, as in the 
kneeling position, or without appreciable cause, severe pain in 
the knee is felt and the joint may be fixed in the position of 
flexion. By massage, manipulation, or spontaneously the foreign 
body is dislodged from between the surfaces of the bones and 
movement becomes free and painless, but discomfort remains for 
a time and in most instances synovial effusion follows. These 
symptoms recur at intervals, and the disappearance of the mov- 
able body from its accustomed place at such times demonstrates 
its relation to the disability. 

Displacement of a Semilunar Cartilage. Displacement of 
a semilunar cartilage is usually of traumatic origin. The internal 
cartilage is usually affected, and it appears to be caused most often 
by an outward twist of the tibia upon the femur. The patient's 
limb is fixed in the attitude of flexion, and in certain instances 
an irregularity may be detected at the inner and upper border 
of the tibia. 

To replace the cartilage the leg should be flexed, then suddenly 
extended and rotated inward. In some instances an anaesthetic 
may be required. The displacement is followed by discomfort 
aud synovial effusion. The accident having once occurred, is 
likely to recur ; the patient recognizing the character of the 
moyements that are likely to cause the displacement, also the 
proper manipulation for its replacement. 

Injury. In other instances somewhat similar symptoms may 
follow injury at the knee, pinchiug of the synovial membrane, 
bruising or fracture of the cartilage, or a strain of one of the 
ligaments within the joint, being assigned as causes. In cases of 

1 W. H. Bennett. Lancet, January 6, 19 



this character, in which symptoms recur from time to time, the 
joint becomes weak and insecure, partly because of the repeated 
synovial effusion and partly because of the muscular relaxation. 

Treatment. If the patient is seen immediately after the dis- 
placement or injury the limb should be fixed in a plaster bandage 
for four weeks or more to allow for reattachment of the displaced 
part. Afterward it may be protected by the adhesive plaster 
strapping, and when the effusion has been absorbed massage and 
exercises for strengthening the muscles should be employed. 

In the more chronic cases in which the ligaments are lax, a 
brace which will permit anteroposterior motion, but prevent 
lateral mobility, may be required. The Campbell brace (Fig. 
176) used by Shaffer, is a light and effective support that inter- 
feres little, if at all, with the use of the limb. 

If the diagnosis of displaced or fractured cartilage can be 
verified, and if it is the cause of persistent disability, it should 
be removed. And the same may be said of isolated foreign 
bodies, which are known to be the cause of the symptoms. 

Under the Esmarch bandage the joint is opened by an incision 
about three inches in length on the anterolateral aspect of the 
joint. After the capsule is opened the leg is flexed to bring 
the cartilage into view. If loose it is then separated from its 
attachments with a tenotomy knife and is removed. The capsule 
is then united with a fine catgut, the wound is closed, and a 
plaster bandage is applied. At the end of a week or more the 
patient may walk about. At the end of a month the adhesive 
plaster strapping may replace the bandage. Perfect functional 
recovery is the rule. The treatment of hypertrophied and con- 
gested synovial membrane, or loose bodies, is conducted in a 
similar manner. 



Acquired Genu Recurvatum. 

Synonym. Back knee. 

Genu recurvatum, as the name implies, is a deformity in which 
the knee is habitually overextended. 

Etiology. Acquired genu recurvatum may be a simple local 
deformity, or it may be secondary to weakness or distortion of 
other parts. Local or primary genu recurvatum may be an effect 
of rhachitis, or of disease or injury of the femur or tibia. In 
this form the femur may be curved sharply forward above the 
joint, or the upper extremity of the tibia may be bent backward 



NQN-TUBEBCULOUS AFFECTIONS OF KNEE-JOINT. 433 

at the epiphyseal junction, and flexion may be limited by the 
obliquity of the articulating surfaces. 

More often the deformity is secondary. It may be, for 
example, an effect of equinus, either congenital or acquired, in 
which the knee is strained by the effort of the patient to place 
the heel upon the ground. It may be caused by the use of a 
brace in the treatment of hip disease, if the knee-joint is not prop- 
erly supported, and it is often seen also as a result of disease at 
this joint, for which no apparatus has been employed. It even 
appears in some instances on the sound side, apparently as a form 
of compensation for the shorter limb (Fig. 189). It is one of the 
comparatively infrequent complications of disease at the knee- 
joint, in which the leg has been supported by the brace in an 
extended or overextended position, or in which the growth at the 
epiphyseal cartilages of the femur or tibia has been irregular. 
In rare instances it is the direct result of traumatism, as when 
the limb has been suddenly forced into an overextended position, 
and the posterior ligaments, and possibly the crucial ligaments 
also, have been ruptured or weakened. It is most often, however, 
an accompaniment of paralysis of the posterior thigh muscles or 
of the gastrocnemius muscle, or both. A slight degree of over- 
extension at the knees is not uncommon in children who have 
the so-called loose joints. 

In many cases genu recurvatum is combined with a varying 
degree of knock -knee, and there is often an abnormal mobility at 
the joint that allows a certain amount of posterior displacement 
of the tibia. In extreme cases of this class there may be well- 
marked subluxation. 

Symptoms. The symptoms, aside from the deformity, are 
weakness and insecurity caused by the hyperextension when 
weight is borne. If the deformity is extreme, the strain upon 
the weakened parts usually causes discomfort. Flexion is ren- 
dered difficult because of the abnormal relation of the joint sur- 
faces and of the accommodative changes in the ligaments and 
muscles, so that in extreme cases the patient swings the leg 
along in the extended or overextended position. 

Treatment. If the recurvation is caused by deformity of the 
bones, the normal relations may be restored by osteotomy of the 
tibia or femur, as may be indicated. Deformity secondary to dis- 
tortions elsewhere may be treated by remedying the primary cause. 

Traumatic genu recurvatum may be treated by fixation in the 
flexed position until the repair is complete, afterward by massage 

28 



43 \ ORTHOPEDIC SURGER Y. 

and support if necessary. The ordinary form of overextended 
knee, combined with lateral mobility, must be supported by a 
brace which permits only anteroposterior motion to the normal 
limit or slightly less. Whenever possible massage and exercises 
should be employed. 

Congenital Genu Recurvatum. 

Synonym. Anterior displacement of the tibia. 

The most common of the congenital deformities at the knee is 
the so-called genu recurvatum, in which the knee is bent some- 
what backward ; or, in other words, the leg is hyperextended on 

Fig. 261. 



Congenital genu recurvatum. (Hoffa.) 

the thigh. The condition is often spoken of as an anterior dis- 
location, but there is no actual displacement, except in the extreme 
cases in which the tibia may be turned directly forward on the 
femur, even to a right angle or less. In the ordinary cases the 
range of extension is merely exaggerated, while flexion is limited 
or checked, principally by adaptive shortening of the quadriceps 
extensor muscle (Fig. 261). In some cases there may be changes 
in the direction of the articulating surfaces in adaptation to the 
deformity of the femur and tibia. 1 

The appearance in well-marked genu recurvatum is very 
peculiar ; it is as if the patient's leg were reversed, for the popliteal 

1 Delanglade. Revue d'OrthopC'die, May, 1903. 



NON-TUBERCULOUS AFFECTIOXS OF KXEE-JOIXT. 435 

depression has become a prominence and the range of overexten- 
sion seems to represent normal flexion. In such cases the leg 
may be brought to the straight line, but greater flexion is resisted 
by the retracted tissues, and when the pressure of the hand is 
removed the leg is drawn back to the deformed position by the 
contraction of the quadriceps extensor muscle. 

Other Deformities and Malformations. Genu recurvatum is not 
infrequently accompanied by varus or valgus deformity at the 
knee, more often by the latter, and by laxity of the ligaments. 
In many instances the patella is absent or is rudimentary, and not 
infrequently the deformity is accompanied by malformations or 
defective development of other parts. 

Seventy-eight cases were collected by Potel. 1 In 37 instances 
the deformity was limited to one side ; in the others both limbs 
were affected. In 50 cases the condition of the patella was noted ; 
in 2<3 of these it was absent or rudimentary. Twenty of the cases 
were accompanied by talipes. 

Etiology. The deformity in cases of simple recurvatum may 
be explained by an abnormal and fixed position in utero, and in 
cases seen soon after birth the mechanism is clearly shown by the 
habitual attitude. The thighs are sharply flexed on the body ; 
the dorsal surfaces of the hyperextended knees are in relation 
to the abdomen, while the feet may be brought into contact with 
the face or trunk, according to the degree of deformity. The 
retarded development of the quadriceps extensor muscle explains 
the rudimentary patella which is often an accompaniment of the 
deformity. 

Treatment. The treatment of the hyperextended knee is very 
simple. It consists in massage of the atrophied and contracted 
muscles, combined with more or less forcible manipulation in the 
direction of flexion. If, as is often the case, the leg seems to be 
drawn forward by spasmodic muscular action, the methodical 
massage should be combined with the use of a simple posterior 
splint 

In the more extreme cases manual force may be applied under 
anesthesia, and tin- deformity may be overcome at one or several 
sittings, according to the resistance of the contracted parts. The 
leg is then fixed in a flexed position until the tendency to recur- 
rence has been overcome. When the child begins to walk a Light 
lateral brace may be accessary to insure perfect functional use of 

1 Etude sur les Malformations Cong6nitale du Genou. Lille. 1897, Imp. L. Danel. 



436 ORTHOPEDIC SURGEll Y. 

the joint, as in many instances laxity of ligaments and muscular 
weakness may persist for a long time. 

Rudimentary or Absent Patella. 

As has been stated, a rudimentary patella is a frequent com- 
plication of genu recurvatum or of any congenital defect or 
deformity of the knee or limb that involves imperfect develop- 
ment of the quadriceps extensor muscle. In many cases of this 
type it is impossible to distinguish the patella during the early 
months of infancy, but later a minute patella appears that slowly 
increases to an approximately normal size. 

Absence of patella under the same conditions is less frequent, 
although Potel collected one hundred cases from literature. 

Treatment. The treatment of rudimentary patella is included 
in the massage and stimulation of the atrophied or rudimentary 
muscle with which it is usually associated, and the support that 
the weak or deformed knee may require. 

Congenital Displacement of the Patella. 

The patella may be displaced upward as a result of extreme 
genu recurvatum, and in rare instances it may be displaced inward 
or downward, but far more often the displacement is outward. 
Fifty cases of this form are recorded, in most of which it was a 
complication of congenital genu valgum. 

Slipping Patella. 

This term is applied to an abnormal laxity of the supporting 
tissues that allows occasional displacement of the patella upon 
or to the outer side of the external condyle. 

Etiology. This disability is more common among females 
than males, and is more often unilateral than bilateral. The 
abnormal mobility may be an inherited peculiarity ; it may be 
due to weakness of the quadriceps extensor muscle, or to imper- 
fect development of the patella or of the external condyle ; or the 
original displacement may have been due to injury. In many 
instances, however, the predisposing cause is genu valgum, as a 
consequence of which the patella is carried toward the external 
condyle. 

Wei ninth 1 has collected 66 cases. Of these 32 were of con- 

1 Deutsche Zeits. f. Chir., Bd. lxi. Bade, Zeits. f. Orthop. Chir., 1903, Bd. xi. p. 3. 



NON- T VBER CULO US A FFECTIOXS OF KXEF-JOIXT. 43 7 

genital, 14 of traumatic (rupture of internal ligaments), and 20 
of pathological origin (knock-knee). 

Symptoms. If the slipping of the patella is a frequent occur- 
rence it causes comparatively little pain, but when the parts are 
less relaxed the displacement is likely to be followed by a certain 
amount of effusion into the joint and by the symptoms of a sprain. 
It is usually the result of a misstep or sudden movement when 
the thigh muscle is relaxed or of extreme flexion of the leg. As 
a rule, there is a sense of insecurity and weakness at the knee in 
those who are subject to the accident. 

Treatment. The treatment varies according to the condition 
of the parts about the joint. If the displacement is the direct 
result of violence the leg should be fixed for a time in a plaster 
bandage, which may be replaced by the adhesive plaster strap- 
ping or a knee-cap. Later massage and muscle training should 
be employed. In cases in which the slipping has become 
habitual and particularly when the ligaments of the joint are 
much relaxed, a light brace should be employed to prevent 
lateral motion and to limit the range of flexion at the joint, if 
this predisposes to the displacement (Fig. 176). 

Operative Treatment. If the position of the patella that pre- 
disposes to the further displacement is a consequence of genu 
valgum the rectification of the deformity will, as a rule, remedy 
the secondary disability. If the displacement appears to be 
caused by laxity of the capsular ligament, as well as by the 
abnormal position of the patella, an operation for the purpose of 
limiting the mobility and restoring the proper relation of parts 
may be conducted in the following manner : A long, curved 
incision is made about the inner side of the knee, the lower 
extremity of which crosses the ligamentum patellae. The skin 
flap having been reflected, the contracted capsule may be divided 
on the outer side without disturbing the synovial membrane. The 
patella is then forced inward and the redundant tissue on the 
inner side is folded and sutured, or a section of the capsule may 
be removed, sufficient in size to hold the patella in its proper 
position. In extreme cases the tubercle of the tibia, with the 
attached tendon, may be removed and reimplanted on the inner 
aspect of the tibia, as performed by Wolff and Walsham. 

The limb should be held in the extended position for a time, 
and it should afterward be supported by a brace or knee-cap for 
ral months. Subsequently massage and exercise for restoring 
the tone of the weakened muscle should be employed. 



l.;s ORTHOPEDIC SURGERY. 

The operation for the dislocated patella has been performed in 
childhood by Pollard, 1 and in early infancy by Bajardi. 2 
The method described is that of Bradford. 3 

Elongation of the Ligamentum Patellae. 

In certain cases the ligamentum patellae may be abnormally 
long, bo that the patella lies habitually above its proper position. 
This elongation may be one of the evidences of general relaxation 
of the ligaments of the knee, and thus a predisposing cause of the 
Blipping patella or of abnormal mobility at the knee-joint. 

Etiology. The elongation of the tendon may be a congenital 
peculiarity or it may be acquired. It is most often observed as 
an effect of anterior poliomyelitis or of hemiplegia or paraplegia. 

Symptoms. The symptoms of elongation of the ligamentum 
patella), as distinct from those of the general laxity of the liga- 
ments that is often present, are weakness and disability, usually 
noticeable on walking up or down stairs, or after overexertion. 
Shaffer, who first called attention to the disability from this cause, 
thinks that it may be a predisposing cause of displacement of the 
semilunar cartilages. 4 

Treatment. In this, as in other forms of insecurity or of 
abnormal mobility at the knee, a brace that allows only antero- 
posterior motion will, as a rule, relieve the symptoms. If the 
ligament is of such a length as to require it, it may be shortened, 
or the tubercle of the tibia may be removed and implanted at a 
lower point, as suggested by Walsham. 5 

Other Congenital Deformities at the Knee. 

Congenital displacements are uncommon. As a rule, they 
are incomplete and are caused by laxity of the ligaments and by 
defective formation of the bones or other parts. 6 

Snapping Knee. 

A very slight form of partial recurrent displacement is the 
snapping or clicking knee not uncommon in early infancy, in 
which the tibia on Budden extension of the limb springs forward 
or rotates outward on the femur with an audible snapping sound. 

' Lancet. 1891. vol. i. p. 988. - Arehiv di Ortoped., 1894, p. 209. 

Transaction" American Orthopedic Association, vol. viii. p. 228. 

xi. 5 Medical Week, February 17, 1893. 

h matin, I'ie Cong. Lux. des Kniegelenks. Zeits. f. Orth. Chir., 1900, Bd. vii. H. 4. 



NON-TUBERCULOUS AFFECTIONS OF KNEE-JOINT. 439 

This movement appears to be the result of voluntary muscular 
contraction combined with laxity of ligaments. In some in- 
stances the subluxation appears to cause pain or discomfort. 
The ability to displace the tibia on the femur by muscular action 
is sometimes fouud in older subjects. Occasionally the snapping 
may be caused by slipping of the biceps tendon. 

Treatment. The treatment of congenital dislocations or sub- 
luxations of the knee consists in reposition, support, and massage 
of the weak part. The snapping knee may be supported by a 
flannel bandage, or, in the more marked type of laxity of liga- 
ments, it may be fixed for a time in a brace. Complete recovery 
is the rule. 

Congenital Contraction at the Knee. 

Slight limitation of the range of extension of one or both knees 
is not infrequent. As a rule, it is easily overcome by massage 
and manipulation. In the more extreme cases there may be an 
accommodative forward bending of the lower extremity of the 
femur, as in certain cases in which flexion follows anchylosis. 

General Contractions. 

Congenital contraction at the knees of a more marked and 
resistant form may be combined with flexion contraction at the 
hips, or it may be one of a series of contractions at other joints. 
In the latter instance other congenital deformities, such as club- 
hand or foot, or evidences of defective development are usually 
present. For example, certain joints may be fixed in flexion or 
fixed in extension. In some instances the contraction or the par- 
tial anchylosis appears to be due simply to long-continued fixation 
in wtero, and to consequent non-development of the muscles. In 
others it appears to be a complication of so-called foetal rhachitis. 

Treatment. The treatment consists in regular massage and 
manipulation, with the aim of increasing the range of motion. 
Deformity, if present, may be rectified in the usual manner. 

Prognosis. The prognosis depends upon the cause of the con- 
traction or fixation. In most instances, under careful and con- 
tinual treatment, the range of motion may be in greal degree 
restored. 



CHAPTER XI. 

DISEASES AND INJURIES OF THE ANKLE-JOINT. 

Tuberculous Disease of the Ankle-joint. 

DISEASE of the ankle-joint is the third in the order of impor- 
tance, although it is far less common than is disease at the knee. 

In five consecutive years 1788 cases of tuberculous disease of 
the joints of the lower extremity were treated at the out-patient 
department of the Hospital for Ruptured and Crippled. In 54.1 
per cent, of these the hip-joint was affected ; in 36.2 per cent, 
the knee-joint, and in but 9.7 per cent, the ankle-joint. 

Fig. 262. 




Tuberculous dlaowe of the ankle and tarsus. A, disease of the ankle and subastragaloid 
oints. B, cavity in the os calcis containing sequestrum. 

Pathology. The pathology of tuberculous disease at the ankle 
differs in no essentia] particular from that of disease of the hip 
and knee. It does not, therefore, call for special consideration. 
It i- of interest to note, however, that abscess is a more common 
complication at this than at the other joints. 

In 30 tinal results of disease at the ankle reported by Gibney, 1 

1 American Journal of Obstetrics, April, 1880. 



DISEASES AXD 1XJURIES OF THE ANKLE-JOINT. 441 

abscess was present in 25 (83 per cent.). In 78 final results 
reported by Prendlsburger 1 abscess was present in 68 (87 per 
cent.), as contrasted with a percentage of 69 and 51 at the knee 
and hip, respectively. This greater liability to abscess is very 
possibly apparent rather than actual, since the ankle-joint is so 
superficial that fluctuation may be detected here that would be 
overlooked at the hip. And because the tissues about the joint 
readily allow spontaneous opening at an early period, before 
sufficient time has elapsed to permit of spontaneous absorp- 
tion. 

Situation of the Disease. Otto Hahn 2 has recently investigated 
the cases of tuberculous disease of the ankle and foot treated at 
Tubingen during the past fifteen years. These cases were 704 
in number in 685 patients, in 19 both feet having been in- 
volved. 

In 309 of the cases the disease was of the ankle-joint. Of 
these 51 per cent. w T ere osteal in origin. The primary focus was 
in the internal malleolus in 11, the external in 7, in both in 5. 
It was in the astragalus in 116 cases. 

In 16 instances the disease of the ankle was secondary to 
primary infection of the os calcis, and in 5 cases both the astrag- 
alus and the os calcis were diseased. 

Etiology. The etiology of tuberculous joint disease does not 
require further comment. It may be noted, however, that tuber- 
culous disease at the ankle is relatively more common in later 
childhood and adult life than is the same affection at the knee 
and hip. 

Of 1000 cases of disease of the hip- joint, 12 per cent, were in 
patients more than ten years of age. 

Of 1000 cases of disease of the knee-joint, 25 per cent, were 
in patients more than ten years of age. 

Of 339 cases of disease of the ankle-joint, 30 per cent, were 
in patients more than ten years of age. 3 

Of the 339 patients 177 were males (52.2 per cent.); 162 
were females (47.8 per cent.). The disease was of the right 
ankle in 173 cases ; of the left in 166. 



1 Loc. cit. 2 Beitrage zur klin. Chir., 1900, Bd. xxvi. II. 2. 

1 Statistics from Hospital for Ruptured and Crippled. 



442 



OR THOPEDIC SURGER Y. 



Age at Incipiency of Ankle-joint Disease in 339 Consecutive 
Cases Treated at the Hospital for Ruptured and Crippled. 



1 


year or less 


. 5 


24 years old . 


. 2 


2 


years old . 


. 42 


25 " 


. 8 


3 




' " 


. 43 


26 " " 


. 3 


4 




' 


. 44 


27 " " . . 


. 4 


5 




' " 


. 34 


28 " " 


. 4 


6 




" . 


. 24 


29 " 


. 2 


7 




' " 


. 19 


30 " 


. 2 


8 




' •' . 


. 8 


31 " 


. 


9 




' " 


. 9 


32 " " . 


. 1 


10 




' " . . 


. 9 


33 " 


. 2 


11 




' " 


. 11 


34 " . 


. 1 


12 




' " 


. 8 


35 " . 


. 


18 




" . 


. 4 


36 " 


. 2 


14 




" . 


4 


37 «« . 


. 2 


15 




" . 


. 4 


40 " 


. 4 


16 




' " . 


. 6 


43 " " 


. 1 


17 




' " . 


. 2 


44 " 


. 1 


18 




« " . 


. 4 


45 " 


. 4 


19 




' " 


. 3 


46 " 


. 2 


20 




' " 


. 3 


48 " 


. 1 


21 




" . 


. 4 


50 " 


. 1 


22 




" . 


. 5 







23 




' " . 


. 2 




339 



Of 658 patients 412 were males (62 per cent.) ; 246 were 
females (38 per cent.). In 27 the sex was not stated. 



Age of the Patients Treated for Ankle-joint and Tarsal 
Disease at Tubingen. (Hahn.) 



1 to 10 years 45 



11 ' 


' 20 " 


21 ' 


' 30 " 


31 ' 


' 40 " 


41 ' 


' 50 " 


51 ' 


1 60 " 


61 ' 


' 70 " 


71 ' 


' 80 " 




81 " 



ales. 


Females. 


Total 


45 


28 


73 


L49 


91 


240 


89 


34 


123 


32 


28 


60 


37 


27 


64 


35 


26 


61 


18 


11 


29 


6 


1 


7 


1 





1 



412 



246 



658 



Symptoms. The symptoms are usually subacute in character, 
and are often mistaken for sprain or rheumatism. In some 
instances they appear to follow an injury, but in the majority of 
cases in childhood no cause can be assigned. The ankle becomes 
sensitive to sudden movements ; the patient limps, and discomfort 
after overuse and pain at night become noticeable. The limp 
differs in character from that caused by hip or knee disease. 
The patient walks with the foot rotated outward, bearing the 
weight upon the heel and upon the inner border, active leverage 
" spring " being avoided. 



DISEASES AXD IX JURIES OE THE AXKLE-JOIXT. 443 

Deformity. The primary deformity of ankle-joint disease in 
the subacute cases is valgus, induced apparently by the continued 
use of the limb in the passive attitude. In more advanced cases 
it becomes equino valgus, and when the limb is no longer capable 
of supporting weight, but is held pendent, the equinus deformity 
predominates, due partly to the force of gravity and partly to 
the muscular spasm. 

Fig. 263. 




Tuberculous disease of the ankle. 

As has been stated, in the early stage the symptoms are those 
of a persistent, somewhat painful disability at the ankle, causing 
stiffness, limp, and at times pain ; later swelling and deformity 
appear. 

Physical Examination. The joint is usually somewhat enlarged. 
In some instances the swelling is uniform ; in others it is local- 
ized in front or behind one of the malleoli. This swelling is not, 
as a rule, like that of simple effusion into the joint, but the 
tissues have the peculiar elastic characteristic of thickening and 
infiltration. There is usually a perceptible increase in the local 
temperature, and pressure directly upon the malleoli causes dis- 
comfort. The voluntary movements of the joint are restricted, 



Ill 



<>immri;i>ic sri:<; /:i: v. 



and passive movements show the characteristic reflex muscular 
spasm, Limiting both dorsal ami plantar flexion. 

Subastragaloid Disease. If the astragalus is primarily diseased, 
the symptoms are usually first apparent in the ankle-joint, but in 
certain cases the joint between the astragalus and the os calcis is 
first involved, the primary focus being in the os calcis. Disease 
at the subastragaloid joint is usually classed as ankle-joint disease, 
although the swelling is most marked at a point somewhat below 
the malleoli (Fig. 264). 

Fig. 264. 




Tuberculous disease of the subastragaloid joint. 



In this form forced lateral motion of the os calcis causes dis- 
comfort, and the range of adduction and abduction of the foot 
is restricted, while dorsal and plantar flexion may remain com- 
pletely free. 

Diagnosis. The principles of differential diagnosis of tuber- 
culous disease from other affections have been considered in 
detail in the description of disease of the spine and of the larger 
joints. 

In childhood a chronic, painful disease confined to a single 
joint in which motion is limited by muscular spasm, and in 



Fig. 265. 




The epiphyses of the lower extremities at the age of six years, showing the effect of oper- 
ative removal of bone at the ankle-joint for tuberculous disease at the age of three years, in 
causing subsequent deformity of the foot and shortening of the limb. Ossification is present 
at birth in the lower epiphysis of the tibia. It begins at the second year in the lower 
epiphysis of the fibula, but not until the fifth year in its upper epiphysis. 



44(3 ORTHOPEDIC SURGERY. 

which there is a tendency to deformity, is almost certainly 
tuberculous in character. 

In adult life also the same statement applies, and distinguishes 
tuberculous disease from rheumatism, rheumatoid arthritis, or other 
general affections. Forms of infectious arthritis may be differ- 
entiated by the history. Sprains or other injury may be distin- 
guished by the history of the onset and by the absence of local 
signs of serious disease. In rigid flat-foot the symptoms are local- 
ized at the mediotarsal joint. It should be borne in mind, also, 
that the pain from a weak or injured foot is experienced, as a 
rule, only when it is in use ; whereas, in tuberculous disease of 
the bone, pain is common when the part is not in use, and it 
may be particularly troublesome at night. 

Treatment. In disease of this, as of other joints, functional 
rest is indicated. This necessitates fixation of the joint and 
stilting of the limb, efficient traction being manifestly impossible. 
The foot should be fixed in a light plaster bandage, extending 
from the extremities of the toes to the calf, at a right angle with 
the leg and in an attitude of slight supination, in order to guard 
against the tendency toward valgus. This deformity is very 
common after the cure of the disease, and it often subjects the 
patient to the additional discomfort of progressive flat-foot. 

Reduction of Deformity. If the foot has become distorted 
before the patient is brought for treatment, the plaster bandage 
may be applied in the attitude of deformity, and at the subse- 
quent applications of the dressing, when the muscular spasm is 
lessened, gentle manipulation will gradually overcome the mal- 
position. In resistant cases immediate reduction of the deformity 
under anaesthesia may be advisable. Throughout the entire 
course of treatment the greatest attention must be paid to the 
attitude. Deformity is easily prevented, but is often very diffi- 
cult to correct, especially during the later stages of the disease, 
when the tissues are infiltrated and sensitive, and especially if 
discharging sinuses are present. 

Other retentive appliances may be employed, but they are 
inferior to a properly applied bandage, which holds its place by 
accuracy of adjustment, which most effectively prevents motion, 
and which exercises a certain degree of compression upon and 
general support of the swollen joint. The bandage is usually 
renewed at intervals of a month, but it may be retained indefi- 
nitely if it is properly protected by a light shoe or slipper. The 
I Her method of passive congestion may be applied at the ankle 



DISEASES AND TNJUBIES OF THE ANKLE-JOINT. 447 

by means of a bandage above the upper border of the plaster 
support. And the adhesive plaster strapping may be used 
beneath the plaster bandage if loeal compression and more 
comprehensive support is desired. 

The most satisfactory brace to serve as a stilt in connection 
with the local support is the Thomas brace, which has been 
described in the section on disease of the knee-joint (Fig. 
258). 

"When patients are treated efficiently the discomfort or incon- 
venience attending the disease is slight. As a rule, the swelling 
of the joint becomes more localized and finally an abscess appears 
beneath the skin. It is then advisable to remove the fluid and 
other contents by means of a simple incision. In most instances 
a sinus persists for a time. If the discharge is slight, the part 
may be dressed with ichthyol, balsam of Peru or other applica- 
tion, and the whole inclosed again in the plaster bandage ; or, if 
it be more profuse, an opening may be made and the dressing 
applied outside the plaster bandage. 

Operative Treatment. Early operation, especially of a gouging 
character, should be avoided. An effective operation of this 
class often involves the sacrifice of bone that would be spared 
in the natural cure, and it entails an irregularity in the growth 
and causes deformity in after-life that may be irremediable (Fig. 
- 5 

Similar operations in the treatment of fistula?, or abscess, while 
the tissues are thickened and eedematous, and while the disease 
within the joint is active, should be postponed until the process 
of repair is more advanced. During the stage of convalescence, 
however, cure may be hastened by the removal of persistent foci 
of disease, or sequestra in the bone, or tuberculous tracts in the 
overlying soft part-. 

In the adult or adolescent, and in exceptional cases in child- 
hood, operative removal of the disease may be indicated. If it 
is confined to the ankle-joint, the removal of the astragali!-. 
which is usually the primary seat of infection, is the operation of 
• •hniee. 

The operation Le performed under the Esmarch bam hi _ 
curved lateral incision is made passing beneath the external 
malleolus from the neighborhood of the tendo Achillis to the 
anterior aspect of the joint The lateral and capsular ligaments 
are divided, after which the foot may be displaced inward. The 
astragalus is sed and it may be removed easily by dividing 



1 |s ORTHOPEDIC SURGERY. 

the Ligaments about its bead and its attachment to the os calcis. 
All the diseased tissue in the soft parts and in the bone must be 
removed thoroughly. If the disease has not extended to the 
tarsus, and if it Beems to have been completely removed, the 
wound may be closed, hut in most cases it should be packed for 

a time with gauze. The after-treatment is conducted as if the 

■ 

operation had not been performed, support and fixation being 
continued until it is evident that the disease is cured. 

Removal of the astragalus does not interfere to a marked extent 
with the function of the foot, nor does it cause noticeable de- 
formity. Ajb a primary operation, permitting inspection and the 
opportunity for thorough removal of all disease in the neighbor- 
ing parts, it should always be performed in preference to exten- 
sive gouging, which is, as a rule, of little avail. 

Prognosis. Disease at the ankle is not only less common, but 
it is less dangerous than that of the larger joints, because it is 
remote from important structures, and because there is less 
opportunity for the burrowing of infected abscesses. The dura- 
tion of the disease here is, as a rule, shorter than at the knee or 
hip, and the final results in childhood are almost always excel- 
lent. Often free motion is retained at the ankle, and even if the 
a-tragalus be fixed by disease the mobility in the other joints of 
the foot is sufficient to compensate very effectively for the 
anchylosis. Shortening of the limb is of comparatively little 
consequence. It is not often more than an inch, and it may be 
absent The growth of the foot is often considerably retarded, 
partly from disuse and partly because of the destructive effect 
of the disease upon the tarsal bones. 

In the 30 cases reported by Gibney, treated expectantly, in 
which the mechanical treatment was far from effective, 6 patients 
recovered with norma] motion; 11 with practically normal func- 
tion. In 7 there was good motion. In 6 there was anchylosis, 
and in :) persistent valgus. In all the limb was efficient. In 20 
instances there was no limp, and in but 1 case was it marked. 
In no instance was a crutch, cane, or other support used. The 
average duration of the disease was three years and three months, 
a minimnm of one year, a maximum of six years. There were 

2 deaths, "f which hut 1 was dependent upon the disease, septi- 
cemia being the cause assigned, though it is stated that practically 
all tie- hone- of the tardus were involved. In this case amputa- 
tion was evidently indicated. 



DISEASES AND INJURIES OF THE ANKLE-JOINT. 449 

Tuberculous Disease of the Tarsus. 

Tuberculous disease of the joiuts of the foot, not involving the 
ankle, is not uncommon. 

In 386 of the 704 cases reported by Hahn, the disease was 
limited to the foot. In 141 cases the mediotarsal joint was 
involved; in 51 of these the disease was confined to this joint; 
in 46 the ankle was involved ; in 29 the disease extended for- 
ward to the tarsometatarsal articulation, and in 16 the three 
joints were diseased. In 78 cases the tarsometatarsal joint was 
involved, in 33 of which the disease did not extend beyond this 
articulation. 

Disease of Individual Bones. In these cases the distribution 
was as follows : 



The astragalus 
The calcaneurn 
The cuboid 
The scaphoid . 
The cuneiform bones 

Metatarsal bones . 



170 ; disease confined to the single bone in 8 



200; 
116; 

82; 



45; 



87 



in one-half of these the disease was 
of the first metatarsal, either alone 
or in connection with the adjoin- 
ing cuneiform bone or phalanx. 



In a total of 1231 cases, including these and others reported 
by Audry, 1 Koenig, 2 Mondan, 3 Munch, 4 Spengler, 5 Vallas, 6 
Czerny," and Dumont, 8 the relative frequency of the disease in 
the bones of the foot and ankle appeared to be as follows : 



Malleoli 


96, 7.7 per cent. 


Scaphoid . 


. 110, 8.9 per cent 


Astragalus . 


. 291, 23.6 


Cuneiform bones 


. 109, 8.8 


Calcaneus . 


. 339, 25.9 


Metatarsus . 


. no, 8.9 


Cuboid 


. 154, 12.5 


Phalanges . 


. 22, 1.7 



Primary Disease of the Astragaloscaphoid Joint. In dis- 
ease at this poiut the swelling is localized in front of the ankle 
on the inner side of the foot. Adduction is restricted, and the 
foot is often fixed in an attitude of persistent abduction. 

Disease of other bones of the tarsus is indicated by the local 
swelling and sensitiveness. The disease sometimes involves the 
shaft of a metatarsal bone, or one of the phalanges, causing 
expansion and destruction, " spina ventosa." 

Treatment of Tarsal Disease. Disease of the tarsus shows 
a marked tendency to extend from one bone to another until the 
entire foot is involved. Consequently if an early diagnosis is 



1 Re%-ue de Chir., 1891. 
Deutsche Chir., 1. 66. 
« Ibid , 1897, Bd. xliv. 
■ Volk. S. klin., v., No. 7-1 



- Schmidt's Jahrb., 1884, Bd. cciv. 
4 Deutsche Zeits. f. Chir., 1879, Bd. xi. 
r > Deutsche Chir., 1., 06. 
* Deutsche Zeits. f. Chir., 1882, Bd. xvii 



29 



450 ORTHOPEDIC SURGERY. 

made of a distinctly Localized process prompt removal of the dis- 
eased bone is indicated ; but in most instances the disease is too 
extensive to permit oi its radical removal. In such eases opera- 
tive intervention i< contra indicated, and the treatment by protec- 
tion, similar to that employed in disease of the ankle, is indicated. 
In childhood the prognosis is very good even when the disease is 
extensive, but in adult life amputation of the foot may be advis- 
able because of the time required to assure a natural cure and 
because an artificial leg provides a better support than a stiff and 
sensitive extremity. Amputation is almost always indicated, 
if there is co-existent disease of the lungs. 

Sprain of the Ankle. 

The ankle is, from its position, especially liable to injury ; in 
fact, the term " sprain " is popularly associated with this joint. 

A sprain is most often caused by an unguarded movement, by 
which the foot is turned suddenly inward or outward, with suffi- 
cient force to injure the synovial membrane, to rupture some of 
the fibres of the muscles, to strain tendons and tendon sheaths. 
and even to rupture ligaments. If the foot is twisted inward 
the injury is most marked on the outer side of the joint : if out- 
ward, on the inner side of the ankle. In the slighter degrees of 
sprain the injury may be confined to the tissues about the joint, 
but in most instances there is effusion within the capsule, even 
hemorrhage when the injury has been severe. 

Symptoms. The immediate symptoms of sprain are pain, 
often intense, of a throbbing character, swelling, heat, and in 
many instances discoloration of the surrounding parts, even 
extending over the leg and foot. 

Treatment. If an opportunity for immediate treatment is 
offered, the swelling and the effusion of blood may be restrained 
by the application of elastic stockinette bandages from the toes 
to the knee. As much compression is exercised as the comfort 
of the patient will allow, and the bandage should be made suffi- 
ciently thick to prevent painful motion. If the injury has been 
severe and if the part is very sensitive to motion or jar, the joint, 
having been protected with cotton, may be fixed in a light plaster 
bandage. This may be cut down the front to allow for daily 

sa ige of the foot, ankle, and leg which is of great service in 
hastening the absorption of the effusion. 

The use of hot air, hot and cold water, and static electricity, 
and the like are of service also in relieving the discomfort and 



DISEASES AND IXJUBIES OF THE ANKLE-JOINT. 451 

especially in stimulating the circulation of the blood, upon which 
repair depends. 

By far the most effective treatment during the stage of recovery 
and as an immediate application for sprains of slighter degree, is 
the adhesive plaster strapping which has been popularized by 
Gibney. His method is as follows : Strips of adhesive plaster 
about three-quarters of an inch in width and from nine to eighteen 
inches in length are prepared. A long strip is placed with its 
ceutre beneath the heel, and the two ends are carried upward 
over the malleoli, to a point at the junction of the middle and 
lower thirds of the leg. A second strip is placed at the pos- 
terior extremity of the heel, and the two ends are carried for- 
ward somewhat beyond the tarsometatarsal junction on either 

Fig. 266. 




A method of applying adhesive plaster strapping for sprain of the ankle. 

side. Another strip is then placed by the side of the first, and 
the fourth by the side of the second, until the entire ankle is 
smoothly covered, except for a space about two inches in width 
directly on the front of the ankle. One takes particular care to 
make the plaster fit well about the malleoli and reinforces it at 
the point- of greatest sensitiveness. A light bandage is then 
applied and the patient is encouraged to use the foot in walking. 
Th*- plaster may be applied in a variety of ways : a satisfactory 
method is as follow-, after the preliminary massage for the pur- 
pose of reducing the swelling : 

One end of a strip of adhesive plaster about three feet long 
and three inches wide is applied to the lateral aspect of the leg 
just below tli*.' knee-joint ; it i- carried down the side of the leg 



452 



orthopedic svnoKi: v 



over the malleolus, beneath the heel and arch, and up the other 
side to a point opposite the beginning, where it is fixed by a cir- 
cular band about the calf. If the sprain is of the outer side of 
the ankle, sufficient tension is made upon the outer half of the 
plaster to hold the foot slightly abducted. If, as is more common, 
the sprain is of the inner side, the inner half is drawn firmly 
beneath the arch, carrying the foot toward inversion so that all 
strain may be removed from the sensitive part. This band of 
plaster is reinforced by one or more so that the lateral aspect of 
the ankle is completely covered. And in addition the entire 
ankle is then inclosed with narrow, overlapping strips which cover 
all the tissues well beyond the sensitive area. The foot and leg 



Fig. 267. 







The stockinette bandage. 



are then bandaged to assure the adhesion of the plaster. When 
the joint is firmly held by the supporting plaster the patient can, 
as a rule, walk with comfort ; and he is encouraged to do so, for 
functional use, provided it does not cause additional injury, is 
the most effective stimulant of the circulation ; thus the patient 
applying, as it were, an automatic massage, cures himself. 

As the swelling subsides the plaster strapping wrinkles, and it 
must be renewed, about three applications being required, as a 
rule, the last of which is allowed to remain until all of the symp- 
toms have disappeared. Vigorous massage before applying the 
new dressing is of service in hastening the cure. It is perhaps 
needless to state that a preliminary shaving of the part will add 
somewhat to the comfort of the patient. 



DISEASES AND INJURIES OF THE AXKLE-JOINT. 453 

Chronic Sprain. 

A chronic sprain may be the result of an inefficiently treated 
acute injury, in which an improper attitude originally assumed 
to spare the sensitive part finally becomes habitual. In other 
instances persistent disability may be the result of fixation of the 
joint for too long a time in splints. Such disuse causes atrophy 
of the muscles and of the bones as well (see Atrophy, page 241), 
while the effused material within and without the joint remains 
because of the imperfect circulation. The same disability may 
follow simple disuse of the injured part. It is more often 
observed in nervous individuals who exaggerate the importance 
of the injury and the discomfort that it causes. In such cases 
the limb may be discolored by venous congestion, the foot may 
be cedematous, and the movements may be limited by adhesions 
or by muscular adaptation to the habitual attitude. 

In other instances the original injury may have caused a slight 
subluxation of the astragalus, sufficient to throw the foot into an 
attitude of abduction, in which it has become fixed by the second- 
ary changes in the muscles and ligaments. In some cases of 
this class the original sprain was at the mediotarsal or at the sub- 
astragaloid joint, and its effect has been traumatic weak foot. 
It may be stated, also, that many of the so-called sprains of the 
ankle are simply injuries of a weak foot, a disability to which 
the treatment should be directed. (See the Weak Foot.) 

Treatment. Treatment must be conducted with the aim of 
re-toring the normal range of motion and so supporting the part 
that normal functional use may be permitted. If adhesions have 
formed and if the foot is persistently held in an abnormal atti- 
tude, forcible manipulation under anaesthesia may be required as 
a preliminary treatment, followed by fixation for a time in a 
plaster bandage, in the attitude directly opposed to that which 
has been habitual. In this class of cases the habitual attitude is 
usually one of equinovalgus ; the foot should be fixed for a time, 
therefore, in a plaster bandage in a position of extreme varus, 
at a right anirle with the leg, and upon it the patient is encour- 
aged to boar hie weight both in standing and walking. When 
all discomfort has disappeared, a support, usually a light leg 
brace to prevent lateral motion, and if the arch is depressed ;i 
foot plate also, should be worn for a time. The most effective 
curative a<rent is functional use, but massage, hot air, passive 
manipulation, and exercises are valuable accessories. 



454 



ORTHOPEDIC SURGERY. 



Injuries of this class are very amenable to treatment, con- 
ducted with the aim of restoring normal function, if proper sup- 
port is provided during the period of pain and weakness. 

Tenosynovitis. 

The sheaths of the tendons about the ankle-joint, if involved 
in a sprain of the ankle, may cause persistent interference with 



Fig. 268. 



Fig. 269. 





The internal annular ligament of the ankle and the arti- 
ficially distended synovial membranes of the tendons 
which it confines. (Testut, from Gerrish's Anatomy.) 

Fig. 270. 




The anterior annular ligament of the 
ankle and the synovial membranes of 

the tendons beneath it artificially dis- The external annular ligament of the ankle and the arti- 

tended. (Testut, from Gerrish's Anal- ficially distended synovial membranes of the tendons 

omy.) which it confines. (Testut, from Gerrish's Anatomy.) 



DISEASES AND INJURIES OF THE ANKLE-JOINT. 455 

function ; or strain of a tendon and of its sheath may cause 
symptoms of disability when the joint is uninjured. The symp- 
toms of acute tenosynovitis are discomfort on motion of the 
affected tendon, and this motion may be accompanied by a pecu- 
liar creaking which is apparent on palpation. In many instances 
there is slight local swelling and sensitiveness to pressure about 
the affected part, and the general movements of the foot that 
call the muscle into action are painful. 

The arrangement of the tendon sheaths should be borne in 
mind. At the ankle-joint all the tendons are provided with 
sheaths ; on the front of the foot are three — the sheath of the 
tibialis anticus, which extends from a point about two inches 
above the extremity of the malleolus to the scaphoid bone (Fig. 
268) ; that of the extensor longus hallucis, from the annular liga- 
ment to the head of the first metatarsal, and the common sheath 
for the extensor communis digitorum, extending from a point 
about half an inch above the malleoli to about one inch below 
the annular ligament. Behind the internal malleolus are the 
common sheaths of the tibialis posticus and flexor longus digi- 
torum, beginning about an inch above the extremity of the mal- 
leolus and extending to the astragaloscaphoid junction, and that 
of the flexor longus hallucis of about the same extent (Fig. 269). 
Behind the outer malleolus is the sheath of the two peronei, 
beginning one inch above the malleolus, dividing into two portions 
for the two tendons and ending just behind the tuberosity of the 
fifth metatarsal bone (Fig. 270). 

Treatment. Simple traumatic tenosynovitis should be treated 
by rest and by compression. An effective treatment is strapping 
with adhesive plaster, so applied as to prevent the movements of 
the foot that cause discomfort. In more painful and persistent 
cases the use of a plaster bandage to assure absolute rest may be 
necessary. Cautery applied over the affected part is of service. 
Chronic tenosynovitis may follow injury or it may be the result 
of gonorrho?a or other infectious disease. In chronic cases when 
the palliative treatment is ineffective, thorough removal of the 
affected sheath is indicated. (See Achillobursitis.) 

Tuberculous Tenosynovitis. A persistent and increasing 
swelling of a tendon sheath always suggests tuberculous disease. 
In such instances the sac is thickened and often contains the 
ailed rir-e bodies. Prompt and complete removal of the dis- 
eased sheath is indicated, and by this means a permanent cure 
raav be attained in most instances. 



456 onriioriwic suiwehy. 



Other Affections of the Ankle-joint. 

The ankle-joint may be the seat of an infectious arthritis ; it 
may be involved in an osteomyelitis of the tibia. It may be one 
of the joints affected in chronic rheumatism or rheumatoid 
arthritis, and occasionally Charcot's disease may appear in this 
situation. The principles of the treatment of these affections 
have been indicated elsewhere. 






CHAPTEE XII. 

DISEASES AND INJURIES OF THE ARTICULATIONS OF THE 
UPPER EXTREMITY. 

Tuberculous Disease of the Shoulder-joint. 

Disease at the shoulder is very uncommon in childhood. In 
a total of 453 cases of tuberculous disease treated at the Vander- 
bilt clinic 210 were cases of Pott's disease. In 6 of the remain- 
ing 243 cases the disease was of the shoulder-joint (2.5 per cent.). 

In 1883 consecutive cases of joint disease — Pott's disease being 
excluded — treated in the out-patient department of the Hospital 
for Ruptured and Crippled during the past five years, the 

Fig. 271. 




v 
Section of the shoulder-joint at the age of eight years. (Schuchardt ) Ossification appears 
in the epiphysis of the head of the humerus at the end of the first year; a second point 
appears in the greater tuberosity during the second year. These unite between the fourth 
and sixth years. Ossification is complete between the eighteenth and twentieth years. 

shoulder-joint was involved in 38 instances (2 per cent.). In 
1 '••' N » cases of joint disease treated at Billroth' a clinic, the shoulder 
involved in 14, or less than 1 per cent. 
Pathology. The disease usually begins in the head of the 
humerus. In 32 observations on adults recorded by Mondan and 
A miry, 1 the primary disease was of the head of the humerus In 
23 cases, of the humerus and scapula in 4, of the scapula alone 
in 1, and in 3 instances it appeared to be primarily synovial. 

■ Revue deChir., 1892. 



ORTHOPEDIC SURGERY. 

In the majority of cases abscess forms and comes to the surface 
near the insertion of the deltoid muscle. In advanced cases the 
tissues of the axilla and of the adjoining thorax may be infiltrated 
and perforated by numerous sinuses. Not infrequently the dis- 
ease is of the form called caries sicca, in which there is no 
swelling, but progressive destruction of the head of the humerus 
by granulation tissue. This form is characterized by extreme 
muscular atrophy and by practical anchylosis. 



Statistics. 

Age at Incipiency of Disease at the Shoulder-joint in Sixty- 
two Consecutive Cases Treated at the Hospital for Rup- 
tured and Crippled. 



1 year or less 


. 1 


13 years old 


. 3 


2 years old . 


. 6 


15 . . 


. 2 


3 "... 


. 1 


18 . 


. . 3 


4 "... 


. 3 


19 . . 


. 5 


5 "... 


. 3 


20 . . 


. 4 


6 "... 


. 1 


23 . . 


. 1 


7 "... 


. 3 


26 . . 


. 2 


8 "... 


. 4 


27 . . 


. 1 


9 "... 


. 6 


34 . 


. 1 


10 "... 


. 1 


48 . . 


. 1 


11 "... 


. 5 


56 . . 


. 1 


12 "... 


. 4 




— 



Total 
Males, 38 ; females, 24 ; right, 35 ; left, 27. 



62 



Town send 1 made a detailed report on 21 cases treated at the 
Hospital for Ruptured and Crippled during the years 1889 to 
1893. Ten of these were less than ten years of age j 7 were 
between ten and twenty, and 4 were more than twenty. The 
youngest patient was three and a half and the age of the oldest 
was thirty-five years. In 5 cases the disease was secondary to 
disease of other parts ; in 1 case to Pott's disease ; in 2 to hip 
disease, and in 2 to disease of the knee-joint. 

Symptoms. The history of the case will show the persistent 
and progressive character of the disability, but the symptoms 
characteristic of tuberculous disease are far less marked at the 
shoulder than at other joints. This is explained by the fact that 
the upper extremity is not subjected to weight bearing and be- 
cause the mobility of the scapula upon the thorax lessens the 
injury caused by unguarded movements of the arm. This double 
joint at the shoulder masks the interference with the function of 
the joint, and the strain caused by overuse may be lessened by 
the unconscious restraint that the patient can exercise upon 

1 Transactions of the American Orthopedic Association, vol. vii. 



DISEASES OF ARTICULATIONS OF UPPER EXTREMITY. 459 

motion at this joint. In fact, even when absolute anchylosis is 
present the patient may think that motion is but moderately 
restricted. 

The symptoms of the disease may be classified as pain, sensi- 
tiveness, restriction of motion, atrophy. 

There is usually a dull ache about the joint, with occasional 
neuralgic pain referred to the elbow and arm. The discomfort 
is increased by movements that pass beyond the limits allowed 
by the mobility of the scapula, especially on attempting to rotate 
the humerus, as in clothing one's self or brushing the hair. The 
joint is sensitive to pressure ; thus the patient finds that he cannot 
lie on the affected side at night. 

The normal range of motion between adduction and abduction 
is about 90 degrees, and between flexion and extension somewhat 
less. 

On examination the limitation of motion caused by muscular 
spasm will be evident when the scapula is fixed, so that movement 
of the joint can be tested. 

Pressure upon the head of the humerus usually causes pain, 
and in many instances local heat and swelling are present. The 
atrophy of the shoulder muscles is often extreme and that of the 
other muscles of the limb is well marked. 

As has been stated, abscess is a common accompaniment of the 
disease, and in such cases the tissues about the joint are swollen 
and infiltrated. In other instances there is progressive destruc- 
tion of the head of the humerus without abscess formation (caries 
sicca). In cases of this type the flattening of the shoulder may 
be so extreme as to be mistaken for subcoracoid dislocation. 

Treatment. The treatment of the disease here as elsewhere 
is rest. To assure absolute functional rest the wrist should be 
attached to the neck by a sling, the elbow being flexed to an 
acute angle ; the arm is then fixed to the thorax by a bandage, 
and all the clothing, including the shirt, is placed outside the 
affected part. Local rest and compression may be still further 
assured by strips of adhesive plaster applied over the shoulder 
and extending to the back and chest ; or a shoulder cap of leather 
or plaster may be employed. This method of fixing the arm is 
the only one that assures continuous rest, as a change of the 
clothing necessitates movement of the joint. During the acute 
phases of tin- <li^ase the arm may be supported in the attitude of 
extreme abduction by means of a triangular splint or pad. This 
position is often that of greatest comfort to the patient. Direct 



460 nliTUOPEDIC SURGERY. 

traction is not often employed, as support of the pendent limb is 
usually preferred by the patient. 

Operative Treatment. If the focus of disease seems to be local- 
ized, an exploratory operation for its early removal may be 
indicated. Excision of the joint in the adult cases, or arthrec- 
tomy in younger subjects, may be advisable when suppuration is 
persistent or when for other reasons it may seem best to attempt 
to remove the diseased area. 

Prognosis. The duration of the disease appears to be from 
two to five years. The death-rate is higher than in disease of 
the joints of the lower extremity, because a larger proportion of 
the patients are adults, and in this class tuberculosis of the lungs 
is not an infrequent complication. 

It is impossible to speak positively of the results of the con- 
servative treatment of disease of the shoulder. The disease is 
uncommon, and protection is almost never applied in the in- 
cipient stage, nor efficiently and persistently employed to the 
end. The ordinary result is, therefore, anchylosis, usually of 
the fibrous rather than of the bony variety. 

If the disease appears in early life the growth of the limb may 
be seriously interfered with ; an inch or more of shortening from 
this cause is not uncommon. 

Tuberculous Disease of the Elbow-joint. 

Tuberculous disease of the elbow-joint is the fourth in order 
of frequency, preceding the shoulder and the wrist. Of 1883 
consecutive cases of joint disease treated at the Hospital for 
Ruptured and Crippled 56 were of the elbow. 

Pathology. The primary disease is in most instances osteal, 
as in 92.8 per cent, of the cases investigated by Scheimpflug, 44 
in number. 1 The original focus of infection is somewhat more 
often of the ulna than of the humerus. Of the ulna the olecranon 
process, and of the humerus the external condyle, appear to be 
the points of election. Disease of the head of the radius is com- 
paratively infrequent. In 119 cases reported by Oilier the 
olecranon was involved in 73, the humerus in 33, and the radius 
in 12 instances. 2 And in the cases investigated by Kummer, 3 
and MiddledorpV tne uma was m ore often the seat of the primary 
disease than was the humerus, but in 81 cases treated in Koenig's 

i Festschrift fiir Billroth, 1892. 

2 Karewski. Chir. Krank. des Kindersalters, p. 268. 

'■' Deutsche Zeits. f. Chir., Bd. xxvii. 4 Archiv f. klin. Chir., Bd. xxxiii. 



DISEASES OF ARTICULATIOXS OF UPPER EXTREMITY. 461 

clinic the primary disease was of the humerus in 43, of the 
olecranon in 36, and of the radius in 2 instances. 1 

Statistics. 

Age at Inctpiency of Disease at the Elbow- joint in Fifty-nine 
Consecutive Cases Treated at the Hospital for Ruptured 
and Crippled. 



1 year or less . 


2 


13 years old 


. 3 


2 years old 


. 5 


14 


" ... 


. 2 


3 " . 


. 8 


15 


" ... 


. 1 


4 " . 


. 5 


17 


" ... 


. 1 


5 " . 


. 5 


19 


" ... 


. 1 


6 '• . 


. 4 


21 


" ... 


. 1 


7 . 


. 8 


23 


" ... 


. 1 


8 " . 


. 1 


25 


" ... 


. 2 


9 '• . 


. 2 


29 


" ... 


. 1 


10 " . 


. 5 






_ 


11 '• . 


. 1 




Total 


. 59 



Males, 28; females. 31 ; right, 27 ; left, 32. 

Symptoms. The symptoms are those of a chronic, persistent, 
destructive disease. Pain, local sensitiveness and swelling, stiffness, 
deformity , atrophy. 

The pain is usually localized at the elbow. It is increased by 
sudden movements, and as the bones are so superficial there is 
usually local sensitiveness to pressure, most marked over the seat 
of the disease. In the early stage the swelling is slight, and it 
is of the peculiar elastic character due to thickening of the tissue 
rather than to effusion within the capsule, but as the disease 
progresses the joint assumes the peculiar spindle shape character- 
istic of white swelling. The degree of elevation of the local 
temperature depends upon the activity of the disease. The 
most important physical sign is the restriction of motion due to 
the characteristic muscular spasm which becomes evident when 
the limit of painless motion is passed. The limitation of exten- 
sion and flexion gradually increases, and finally the limb becomes 
fixed in an attitude midway between flexion and extension, with 
the forearm in an attitude between pronation and supination. 
This is the characteristic deformity of the disease. 

Atrophy of the muscles of the arm and forearm is present, 
corresponding to the intensity and duration of the disease and to 
the functional disability of the joint. 

Treatment. The treatment here as elsewhere consists essen- 
tially in placing the joint at rest in the attitude at which anchy- 
losis or limitation of motion will least inconvenience the patient, 

' Koenig. Lehrbur h Spec. Chir., Berlin, 1900. 



162 



<>irru<>i>i:i)ic SUBQEBY. 



and at t lit' elbow-joint this is practically at right angular flexion 
(Fig. 273). 

In the treatment of young children the wrist may be attached 
closely to tin* neck by means of a sling, with the elbow at an 
acute angle (the Thomas method) within the clothing. Or a 
Light plaster bandage may he used to fix the joint, the wrist being 
support ed by a -ling. This enables the patient to dress himself 
without moving the part, and it protects the joint from injury. 
Other forms of splints may be employed, but the plaster bandage 

Fig. 272. 




Tuberculous disease of the elbow-joint. 



answers every purpose. It should, of course, extend from the 
axilla to the hand, and in sensitive cases it may include the hand 
also. 

Reduction of Deformity. In many instances the arm is fixed in 
the semi-extended attitude when the patient is brought for treat- 
ment. In this class of eases a simple and effective means of 
reducing deformity is that suggested by Thomas. When it is 
impossible to bring the wrist to the neck, one bends the neck 



DISEASES OF ARTICULATIONS OF UPPER EXTREMITY. 463 

toward the wrist and attaches the two by a bandage that the 
patient is unable to remove. From this uncomfortable attitude 
the patient can free himself only by drawing the arm toward the 
neck and thus reducing the deformity. At the next visit the 
same procedure is repeated, until finally the elbow is flexed to 
the required degree. A permanent sling may be constructed of 
a leather wrist-band and a tube of leather to pass about the neck, 
through which the bandage may be drawn ; thus the pressure on 
the wrist and neck may be lessened. In the very resistant cases 



Fig. 2Ti 




Tuberculous disease of the elbow-joint ; the stage of recovery. 



reduction of deformity under anaesthesia may be required, but 
this i- not often necessary. 

Prognosis. If the case is treated at an early stage the prog- 
nosifl in childhood is good. The duration of treatment may be 
estimated at two years or more, and retention of a fair range of 
motion may be expected. Anchylosis in the right-angled position 
does not, however, seriously inconvenience the patient, provided 
the cure i- absolute. The loss of growth is usually less than 
when the upper epiphysis of tin- humerus has been destroyed, the 



L64 ORTHOPEDIC SURGERY. 

final disproportion depending, of course, upon the age of the 
patient and upon the degree of function that is preserved. 

Operative Treatment. In some instances it is possible to re- 
move small foci of disease from the humerus, or from the ulna, 
before the join! la involved. The position of the disease may be 
indicated by sensitiveness or swelling, and in older subjects a 
Roentgen picture may demonstrate its position accurately. 

Excision of the Elbow. Excision is often advisable in adolescent 
or adult life, because by this procedure, in most instances, the dis- 
ease may be cured in a definite time and because a movable joint 
may be assured. 

Oschman has recently investigated the final results of the 
operation performed on this class at KocherV clinic at Berne, 
1872—1 81>7. In 40 of 45 cases the operation was performed for 
tuberculous disease. There were no deaths referable to the 
operation. Of the entire number of cases 15 were dead, but 11 
of these survived the operation for from five to twenty years. 
Eight of the deaths were due to tuberculosis, 2 to other causes, 
and in 5 the cause of death was unknown. In 96 per cent, of 
the cases the local disease was cured. In 68 per cent, of the 
cases the patients were able to use the limb at hard labor, and in 
the others it was efficient for light work. In 6 cases there was 
subluxation or luxation ; in 5 the joint was not firm. In 59 per 
cent, the motions were practically normal. In 11 per cent, the 
joint was anchylosed. 

Tuberculous Disease of the Wrist-joint. 

Disease of the wrist-joint is very uncommon in childhood. In 
;i total of '3105 cases of tuberculous disease treated in the out- 
patient department of the Hospital for Ruptured and Crippled 
during the past five years, 98 were of the upper extremity, and 
in hut 4 of these was the wrist- joint involved. Of 43 cases in 
which the joint was resected by Oilier, the youngest patient was 
thirteen years of age. 

Of {»!*<» cases of disease of the joints in childhood, reported by 
Karewski, the wrist was involved in 31. 2 

Disease of tin- wrist in older subjects is less infrequent, although 
at all ages it is rare as compared with disease in other joints. 
Tuberculous disease of the metacarpus and phalanges (spina 
ventosa) is, however, far more common. 

hiv f. kiln. Chir., 1900, Bd. lx. H. 2. 
- Chir. Krank. des Kindersalters, Berlin, 1894. 



DISEASES OF ARTICULATIONS OF UPPER EXTREMITY. 465 

Age at Ixcipiexcy of Disease at the Wrist-joint in Eighteen 
Consecutive Cases Treated at the Hospital for Ruptured 
and Crippled. 



2 years old . 


• 




. 1 


19 years old 


2 


6 






. 1 


20 . . . 


. 2 


9 






. 1 


25 . 


. 2 


12 






•j 


26 " . 


. 2 


14 






. 1 


27 . 


. 1 


16 






2 




— 


17 






. 1 


Total 


. 18 




Males, 


11 


females, 


7 ; right, 12 ; left, 6. 





Symptoms. The symptoms of tuberculous disease of the wrist 
are, as in other situations, pain, local swelling and sensitiveness, 
limitation of motion, caused by muscular spasm, and atrophy. In 
advanced cases the hand is usually flexed somewhat upon the 
arm. 

Fig. 274. 




Tuberculous disease of the wrist and knee-joints, showing the characteristic 
deformities in neglected cases of a severe type. 



Treatment. The treatment of this, as of other joints, is func- 
tional rest, with support in the attitude in which anchylosis or 
limitation of motion will cause the least inconvenience. A light 
plaster bandage extending from the elbow to the tips of tin; 
fingers, applied over a flannel bandage drawn as tight as the com- 
fort of the patient will permit, is a satisfactory support ; or a 
leather splint or other form of appliance may be used. The hand 

30 



466 ORTHOPEDIC SURGERY. 

should be held in an attitude of moderate dorsal flexion, which 
will permit the flexor muscles to close the fingers easily if the 
wrist becomes fixed by the disease. If flexion deformity is 
present it should be corrected by degrees, with each application 
of the bandage, until the desired attitude is attained (Fig. 275). 
The flannel bandage exercises a certain amount of compression 
upon the wrist which seems to be of benefit, and in certain 
instances this compression and fixation may be still further in- 
creased by the application of adhesive plaster. When the disease 
of the joint is quiescent, or in the stage of recovery, the bandage 
or splint may be shortened to allow the patient to use the fingers. 
Prognosis. The prognosis as regards function in cases treated 
promptly in childhood should be good. In the adult cases wrist- 
joint disease seems to be very often complicated by disease of the 
lungs ; thus the prognosis as to life is often bad. In this class 
of cases early excision is usually recommended, with amputation 
as a final resort. 

Spina Ventosa. 

Central disease of the long bones of the foot and hand is 
the most common form of diaphyseal tuberculosis. While the 

Fig. 27^. 




Treatment of tuberculosis of the wrist-joint by plaster of Paris, showing the 
proper attitude. 

cortical substance is destroyed from within it is often replaced 
in part by a formation of periosteal bone from without, which 
in turn may be destroyed by the advancing disease. In the 
early cases the affected bone is enlarged, spindle-shaped, and is 
somewhat sensitive to pressure. At this stage repair may take 
place with but little ultimate change from the normal, but in 
many instances the bone is perforated and in part destroyed, the 



DISEASES OF ARTICULATIONS OF UPPER EXTREMITY. 467 

neighboring joint is involved, and the finger becomes stunted and 
distorted. 

Fig. 276. 




Tuberculous disease of the carpus. 
Fig. 277. 




Tuberculous disease of the left wrist-joint. The irregularity and the diminished size ot 
the carpal bones indicate the extent of the destructive process. The patient, the mother of 
the child (Figs. 10 and 11 ) with Pott's disease, died within a year, of tuberculosis of the lungs. 

In 159 cases tabulated by Karewski, 1 the metacarpal bones 
were diseased in 65 instances ; the phalanges in 57 ; the meta- 
tarsal bones in 29 ; the phalanges of the toes in 8. In a number 



Chir. Krank. des Kindersalters, Berlin, L894. 



HiS ORTHOPEDIC SURGERY. 

of instance- several of the hones and larger joints were involved 
(159 cases in L35 patients). 

The disease is more common in the early years of life, 84 of 
the 135 patients being four years of age or less, 38 of these 
being less than two. 

Spina ventosa of the phalanges may be treated by rest and 
compression, and both splinting and compression may be exer- 
cised by adhesive plaster strapping. If the joint is involved 
amputation of the finger may be indicated, because of the dis- 
tortion and loss of growth that may be expected. Tuberculous 
disease, limited to a single bone of the carpus or metacarpus, may 
be treated by operative removal of the disease. 

Periarthritis of the Shoulder. 

Under the title of scapulohumeral periarthritis, Duplay 1 in 
1872 described a painful affection of the shoulder induced by 
traumatism, dependent upon an inflammation of the bursa lying 
between the deltoid and supraspinatus and infraspinatus muscles 
and the coracoacromial ligament. But under this title are now 
included a number of affections that cause similar symptoms in 
which it would appear that the interior of the joint is not in- 
volved. 

Symptoms. In a typical case of so-called periarthritis the 
patient complains of a dull pain about the joint and sensitiveness 
to pressure just below the acromion process or over the bicipital 
groove. The pain is increased by motion, particularly by abduc- 
tion or by rotation of the arm. In mild cases only extensive 
motion causes pain, but in most instances there is a constant sen- 
sation of discomfort which is increased to acute pain by sudden 
movements or jars. The part becomes sensitive to pressure, so 
that the patient avoids lying on the shoulder at night. In cer- 
tain instances the pain may radiate down the arm, and there may 
be weakness and numbness of the fingers. Gradually the passive 
movements of the joints are diminished in range, and atrophy of 
the shoulder muscles appears. 

These symptoms usually pass as rheumatism, but there is no 
fever, no involvement of other joints, no swelling, and, as a rule, 
no general sensitiveness to pressure, as is usual when the synovial 
membrane of the joint is affected. In certain instances these 
symptoms follow injury, or exposure to cold, or they appear 

1 Archiv. g6n6rale de Med., Paris, 1872. 



DISEASES OF ARTICULATIONS OF UPPER EXTREMITY. 469 

without apparent cause. In one class of cases the symptoms may 
be due to an inflammation of the subdeltoid bursa, as in the cases 
originally described by Duplay ; in others to a tenosynovitis of 
the biceps tendon that may extend to the surrounding parts. 
This is suggested by local sensitiveness at the bicipital groove, 
and by the creaking sensation at this point when the muscle is 
in use. Or the symptoms may be due to neuritis affecting the 
circumflex nerves, as suggested by Amidon. 1 It is probable also 
that the nerves in the neighborhood of the joint may be second- 
arily implicated in an inflammation of bursae, or directly injured 
by the original traumatism, if such preceded the symptoms. It 
is also possible that the bursitis may have been a sequel of 
gonorrhoea or of other infectious disease. 

Treatment. During the acute and painful stage the part 
should be kept at rest. Cautery may be applied and the joint 
should be inclosed in adhesive plaster strapping, and if the 
weight of the limb causes discomfort it should be supported. 
In certain instances tension on the sensitive part may be relaxed 
by supporting the arm in an attitude of abduction. When the 
acute symptoms have subsided passive movements, massage, and 
static electricity are of service. Voluntary exercises should be 
employed when they no longer aggravate the symptoms. In the 
cases of long standing in which motion is very much restricted, 
apparently by adhesions without the joint, passive movements 
under anaesthesia may be of benefit. In such cases it may be 
well to support the limb for a time in the abducted attitude to 
prevent the formation of the adhesions. Afterward passive 
motion, massage, and exercises may be employed. If these cases 
are treated carefully in the early stage, recovery is usually rapid, 
but if neglected the symptoms may persist indefinitely 

Chronic Bursitis. 

Chronic bursitis at the shoulder-joint is comparatively infre- 
quent. The bursae most often involved are the coracoid, the 
subscapular, and the deltoid. Of these the last is the most often 
affected. Sixteen cases have been reported by Blauvelt, 2 and 
three others by Ehrhardt. 3 The enlarged bursa forms a fluctuat- 
ing swelling most evident on the anterior and outer aspect of the 
shoulder, the symptoms being discomfort, weakness, and limita- 

1 American Medico- Surgical Bulletin, March 21 

2 Beitrage zur klin. Chir., Bd. xxii. Arcbiv f. klin. Chir., 1900, Bd. lx. 



i;,) ORTHOPEDIC SURGERY. 

tion of motion of the arm. The disease is usually tuberculous in 
character, and it should be treated by incision or by complete 
removal of the sac if possible. 

Sprain of the Wrist. 

This is a very common accident. The most effective treatment 
is the adhesive plaster strapping applied about the metacarpus, 
wrist, and lower half of the forearm. If the pain on motion is 
severe 1 sufficient plaster is applied to splint the part and to limit 
movement to the point of comfort. If the injury is of a slighter 
grade the compression and support of a siugle layer of plaster 
is usually sufficient. This dressing prevents injury and yet it 
allows a certain degree of functional use, which is the most effec- 
tive means of restoring a joint to its normal condition by hasten- 
ing the absorption of the effused material within and without 
the joint. 

Chronic Sprain. Persistent weakness and stiffness may follow 
treatment of a sprain by splints, or when for any reason disuse of 
function has been long continued. In many instances, however, 
the sprain was in reality a fracture or displacement. All chronic 
sprains, therefore, should be examined by means of the X-ray in 
order that the presence or absence of more extensive injury may 
be determined. 

The treatment is similar to that of the acute sprain : protection 
from injurv, and functional use to the extent of which the part is 
capable. With this, massage, hot air, and electricity or other 
form of local stimulation may be employed with advantage. 
The same treatment is indicated when the joint is stiff and painful 
as the result of rheumatism or other inflammation, provided the 
stage of recover*} 7 has been reached. 

Acute Tenosynovitis. 

Tenosynovitis is common at the wrist-joint. It is usually 
induced by strain or overuse of a muscle or muscular group. 
Movements <»f tin- muscles that are involved cause discomfort, 
and there is usually local x-nsitiveness and a creaking sensation 
on palpation over the affected tendon sheath. The adhesive 
plaster strapping, 90 applied as to exert compression and to pre- 
venl the motion that cause- discomfort, is the most effective 
treatment. 



DISEASES OF ARTICULATIONS OF UPPER EXTREMITY. 471 

Chronic tenosynovitis, causing progressive enlargement of a 
tendon sheath with accompanying symptoms of weakness and 
discomfort, is usually tuberculous in character. In such cases 
the diseased part should be promptly removed. If the disease is 
of long standing, extending into the palm of the hand, it may 
be advisable to simply evacuate the contents, including the rice 
bodies, through an incision. An astringent solution may be 
injected, and after its removal the incision may be closed. 
Pressure is then applied, with the aim of securing partial 
adhesions of the apposed surfaces. 



CHAPTER XIII. 

DEFORMITIES OF THE UPPER EXTREMITY. 

Congenital Dislocation of the Shoulder. 

This may occur in two forms, one in which there is actual 
misplacement before birth, and the other in which a dislocation 
is caused by violence at birth. In either case the displacement 
is almost always backward upon the dorsum of the scapula 
(subspinous). Thus the arm is abducted and rotated inward, 
and the head of the displaced bone may be felt in its abnormal 
position. Cases of congenital displacement in other directions 
are recorded, but these are so unusual as to be of little practical 
importance. 1 

True primary displacement of either variety is uncommon. 
Many of the reported cases were apparently subluxations secondary 
to the relaxation of the capsule of the joint and to the muscular 
atrophy caused by anterior poliomyelitis, or more often to the 
habitual malposition due to obstetrical paralysis (Fig. 278). 
According to Porter, 2 twenty -nine cases are recorded in literature, 
in at least half of which the diagnosis is doubtful. It is, of 
course, apparent that both displacement and paralysis may be 
coincident and caused by injury at birth. 

Treatment. The only treatment of a dislocation is replace- 
ment of the displaced bone if it be possible. If the displacement 
were discovered in infancy it should be possible to reduce it by 
manipulation, especially if it were of traumatic origin. As a 
rule, however, the cases are not seen until later childhood, when 
the accommodative changes are so great as to make reposition 
difficult. 

Phelps, of New York, has reported several cases of congenital 
dislocation of the shoulder, caused apparently by injury at birth, 
afl most of them were accompanied by paralysis. In the first 
case (a boy eight years of age) the joint was opened by a posterior 
incision along the border of the deltoid muscle. The head of 

1 Scudder. American Journal of the Medical Sciences, February, 1898. 
- Transactions of the American Orthopedic Association, 1900, vol. xiii. 



DEFORMITIES OF THE UPPER EXTREMITY. 473 

the scapula was found to be atrophied, and the posterior margin 
of the glenoid cavity broken away. This, together with the 
contraction of the tissues on the anterior aspect of the joint, made 
it necessary to cut away a part of the head of the bone in order 
to replace it. The secondary articulating surface on the scapula 
was excised and the redundant capsule was removed. The 
immediate result of the operation was very favorable. Phelps 
states that he has operated on two similar cases, but a final report 
of the results has not been presented. 1 In all cases of this char- 
acter limitation of motion or even anchylosis is to be expected. 

It would seem, however, that, as in a posterior displacement 
the contracted tissues must be those in front of the joint, an 
anterior rather than a posterior incision would be preferable. 
In any event prolonged forcible manual stretching of the con- 
tracted parts, in the manner described in the treatment of 
congenital dislocation of the hip with the aim of securing bloodless 
reposition, should precede the open operation. By this means the 
writer has reduced the displacement easily in several cases in 
early childhood. After reduction the limb should be fixed for 
months in the attitude of extension on the scapula, so that the 
head of the humerus may be forced forward, and it should be 
rotated outward in order to overcome the tendency to inward 
rotation that is almost always present. When the parts have 
become adapted to one another the support is removed, and 
manipulation and exercises are then employed, as in the after- 
treatment of congenital dislocation of the hip. If the bone 
cannot be retained in proper position, and especially in those 
cases in which the paralysis is extensive, the joint may be opened 
by an anterior incision, and the cartilage may be removed 
from the humerus and scapula, with the aim of obtaining bony 
anchylosis. (See Arthrodesis.) 

Obstetrical Paralysis. 

Partial or complete paralysis of the muscles of the arm 
may be a result of difficult or protracted labor. It may be 
caused by direct injury of the brachial plexus, but most often 
it is caused by traction on the body or the head, and by 
violent twists of the neck during delivery. The muscles most 
often paralyzed are those supplied principally by the fifth and 
sixth cervical roots of the plexus, the deltoid, the biceps, and the 

1 Transactions of the American Orthopedic Association, vol. viii. 



171 



OIITIIOVEDIC SURGERY. 



Fig. 27S. 



supinators of the forearm. 1 Thus in most instances the arm 
hangs in an attitude of slight abduction and exaggerated prona- 
tion (Fig. '27 8). If the attitude is allowed to persist and if the 
paralysis is permanent, the head of the humerus, rotated backward 
beneath the atrophied deltoid muscle and held in the abnormal 

attitude by accommodative 
changes in the capsule and 
surrounding parts, simulates 
very closely in later years the 
true congenital dislocation of 
the shoulder (Fig. 279). 

Whether cases reported as 
congenital displacement of 
the shoulder are secondary to 
paralysis or not, it is evident 
that all cases of obstetrical 
paralysis should be carefully 
examined with regard to a 
complicating dislocation, and 
that the secondary deformity 
induced by paralysis should 
be prevented. 

Treatment. During the 
first month after birth the 
shoulder of the paralyzed arm 
is often somewhat swollen, 
and motion may cause pain. 
In such cases rest is in- 
dicated. The arm should 
be placed against the side, and the hand, with the fingers 
extended, should be supported on the chest beneath the clothing. 
When the primary sensitiveness has subsided, each of the joints 
of the extremity should be moved systematically to the limits of 
the normal range of motion several times in a day. Particular 
care should be exercised in supinating the forearm and ex- 
tending the wrist and fingers, if they are involved in the 
paralysis. The muscles should be massaged, and the arm should 
be supported by a sling, or otherwise, in proper position. 
Recovery may be complete, although it is often delayed for 
many months. As a rule, traces of the injury are evident in 




Obstetrical paralysis. Characteristic attitude. 



Thomas. Johns Hopkins Hospital Bulletin, November, 1900. 



DEFORMITIES OF THE UPPER EXTREMITY 



475 



atrophy of certain muscles, particularly of the deltoid, and a 
certain weakness of the arm persists, even though no paralysis 
remains. 

In many instances recovery is but partial, the arm is weak, 
certain muscles are paralyzed, and there is much restriction of 
movement at the shoulder. The growth of the member is re- 
tarded, and the attitude simulates that of posterior dislocation, as 



Ftg. 279. 




Obstetrical paralysis in adolescence. 



has been stated. Even in such cases massage, exercises and 
training will often improve the functional ability of the disabled 
part. If from neglect of treatment subluxation of the humerus 
is present, it should be reduced by manipulation in the manner 
described. In certain cases of this character function may be 
greatly improved, if the operation is supplemented by massage 
and appropriate training. 



17,; ORTHOPEDIC SVllUERY. 

Recurrent Dislocation of the Shoulder. 

Recurrent dislocation of the shoulder is in most instances a 
sequel to traumatic dislocation. The cause of the instability is 
usually laxity of the capsular ligament and weakness of the sup- 
porting muscles, the result, it may be, of too early use of the 
arm after the accident. In rare instances greater derangement 
of the joint, caused by fracture of one or other of the articulating 
surfaces, rupture or displacement of ligaments or muscles, or 
permanent paralysis of the deltoid muscle, may be present. 

The displacement, which may be partial or complete, recurs at 
intervals and is a very serious disability. 

Treatment. If the patient is seen immediately after a dis- 
placement and if the dislocation has recurred but a few times and 
at long intervals, it may be inferred that the disability is the 
result of simple laxity of the capsule and of muscular weakness. 
In such cases a period of fixation followed by massage and exer- 
cise of the atrophied muscles may result in cure. The patient 
should be carefully questioned as to the particular movements of 
the arm that are likely to cause the displacement, which is, as a 
rule, forward beneath the coracoid process. Most often elevation 
and abduction seem to be the predisposing movements that 
should be restrained. A simple and often an effective means of 
treatment is the application of a shoulder cap of canvas that fits 
closely about the shoulder and upper arm. This is held in place 
by bands crossing the body and buckled beneath the other arm ; 
from the lower border of the cap one or more bands pass down- 
ward and are attached with the braces to the trousers, so that 
elevation of the arm is restrained, before the point of instability 
is reached. 

Operative Treatment. If these milder measures are ineffective, 
an operation to reduce the size of the lax capsule may be per- 
formed according to the method employed by Burrell. The arm 
being slightly abducted, an incision is made from the coracoid 
process downward and outward along the line of the cephalic 
vein to a point below the upper border of the tendinous insertion 
of the pectoral is major. The deltoid and the pectoralis major 
are separated, exposing in the upper border of the wound the 
ooraeobrachialis, and in the lower angle the upper part of the 
insertion of the pectoralis major muscles. The upper three- 
fonrthfl of thi> insertion is divided in order to expose the head 
and neck of the bone. The humerus is then rotated outward 



DEFORMITIES OF THE UPPER EXTREMITY. 477 

and a portion of the insertion of the subscapulars muscle, 
stretched over the head of the humerus, is divided. The capsule 
is thus laid bare. 

In Burrell's second case a portion of the anterior wall of the 
capsule three-eighths of an inch wide and three-fourths of an 
inch long was excised, and the wound was closed with sutures. 
The incised muscles fell into apposition when the arm was fixed 
to the side. Burrell has operated on two patients by this method 
with perfect success. 

Similar operations in which the lax capsule was overlapped 
and sutured without opening it have been performed, by Ricard 
in 1892 and by Steinthal in 1895. l 

Congenital Deformities of the Elbow. 

Congenital displacement of the ulna is one of the rarest of 
deformities. The displacement is usually incomplete, and it is 
associated with laxity of the ligaments. 

Congenital displacement of the radius is much more common. 
Thirty cases collected from the literature have been reported by 
Bonnenburg.* The symptoms are similar to those of traumatic 
dislocation. The deformity is often overlooked in childhood, and 
as it causes no great disability, treatment is not usually desired. In 
several instances the head of the radius has been removed with a 
favorable effect in increasing the range of supination. 

Cubitus Valgus, Cubitus Varus. 

Cubitus valgus, in which the forearm is abducted at the elbow, 
and cubitus varus, in which it is inclined in the other direction, 
are occasionally seen as congenital deformities. They arc, in 
most instances, associated with laxity of the ligaments. 

Similar deformities are not uncommon during the progressive 
stage of rhachitis, but they usually disappear when the erect 
attitude is assumed and when the arms are relieved of the strain 
of supporting the body in the sitting posture. 

The forearm forms an angle with the upper arm, opening 
outward when the limb ia extended at about 17:> degrees in 
males and 167 degrees in females. 3 This is sometimes called 
the " carrying" angle, because the hand is held at some distance 

1 Burrell and Lovett. American Journal of the Medical Sciences, August. I 

2 Zeits. f. Orth. Chir., Bd. ii. 

• Potter. Journal of Anatomy and Physiology, vol. xxlx, | 



17s ORTHOPEDIC SURCERY. 

from the body while the arm is in contact with the trunk. What 
may be called normal cubitus valgus is common among women, 
and in certain instances it may be exaggerated to deformity. 
Acquired cubitus varus is usually the result of direct injury. 
Both deformities may he treated by osteotomy of the humerus 
just above the articulation after the method used to correct 
similar deformity at the knee. 

Subluxation of the Wrist. 

A peculiar displacement of the hand forward and usually toward 
the radial side, described by Madelnng 1 as " spontaneous subluxa- 
tion," is sometimes seen in young subjects whose occupation may 
require constant use of the flexors of the hand and fingers. In 
these cases the lower extremity of the ulnar is displaced toward 

Fig. 280. 




-]<>ntaneous subluxation of the wrist. 

the dorsum of the hand ; there is abnormal separation of the two 
bones of the forearm from one another at the wrist, and in many 
instances the lower extremity of the radius is bent forward. As 
a consequence the wrist is enlarged, the ligaments are relaxed, 
and dorsal flexion of the hand is restricted. The symptoms, 
aside from the deformity, are weakness and sensations of discom- 
fort about the dorsum of the wrist. 

Etiology. The predisposing causes of the affection are, 
apparently, relaxation of the ligaments, and, possibly, slight 
pre-existing rhachitic deformity of the same character. The 
exciting causes are occupation or injury. The slight forward 
bending of the lower extremity of the radius is due, apparently, 
to irregularity in growth at the epiphyseal junction. 

1 Arcbiv f. klin. ehir., Bd. xxiii. 



DEFORMITIES OE THE UPPER EXTREMITY. 479 

Treatment. The treatment is rest, massage, forcible manipu- 
lation in the direction of extension, and a support of leather or 
other material to hold the hand in the extended position. In 
more extreme cases the deformity of the radius may be overcome 
by osteotomy. 

Congenital Deformities at the Wrist. 

Simple congenital dislocation of the wrist is extremely rare. 
Displacement of the wrist and hand is usually associated with 
defective development of the bones of the arm, and the deformity 
is usually classed as club-hand. 

Club-hand. 

Congenital distortions of the hand may be divided into four 
primary varieties, according to the direction in which the hand is 
turned, viz. : 

1. Forward or palmar. 

2. Backward or dorsal. 

3. Lateral to the radial side — radial. 

4. Lateral to the ulnar side — ulnar. 

Lateral and anteroposterior distortions occur also in combina- 
tion. 

Etiology. There are two distinct varieties of club-hand : 

1. In which there is simple distortion caused apparently by 
abnormal restraint and pressure in utero. In certain cases of 
this class there may be limited motion at both the shoulder-joint 
and elbow-joint and defective muscular development apparently 
dependent upon long-continued fixation. 

2. In which the deformity is associated with defective develop- 
ment of the radius or ulna and often with congenital abnormali- 
ties of other parts. 

In the palmar and dorsal distortions the bones of the arm are 
usually normal. The lateral deviations of the hand are often 
complicated by defective formation of the radius or ulna, and 
thus they correspond to talipes due to absence of the tibia or 
fibula. 

According to Hoffa, 1 39 cases of the former and but 6 of the 
latter are recorded ; in but 1 case was there entire absence of ili< 1 
ulna. Of the 39 cases of radial club-hand 19 were of both sides, 

1 Lehrb. der Orth. Chir., p. 481. 



ISO 



orthopedic suiwery. 



These statistics, however, by HO means represent the relative fre- 
quency of the deformity. From the writer's observation it 
would appear that radial club-hand is nearly as common as the 
deformity of the foot caused by absence of the fibula, of which, 
according to Potel, there are 200 recorded cases. The ulnar 
form of club-hand is less frequent even than the deformity due 
to defective formation of the tibia. 

The most important form of club-hand is, then, that due to 
absence or to defective formation of the radius. As in talipes 
valgus due to absence of the fibula, the tibia is short and often 



Fig. 281. 




Club hands and club feet. 



bent sharply forward, so in this form of club-hand the ulna is 
usually short and bent inward. The hand may be perfect in 
formation, but, as a rule, the thumb is absent or rudimentary, 
and other adjoining bones, together Avith the corresponding liga- 
ments and muscles, may be absent also (Fig. 282). 

The hand occupies practically a right-angled relation to the 
ulna, and as this bom- is usually bent inward as well the direction 
of the hand i- often nversed and is parallel to the forearm. As 
a rule, the hand i< also somewhat bent forward, so that the 
deformity might be described as radiopalmar (Fig. 283). 



DEFORMITIES OF THE UPPER EXTREMITY. 



481 



Treatment. In those forms of club-hand in which the struc- 
ture is normal the deformity may be overcome, as a rule, by 
manipulation, and support by the plaster bandage or otherwise, 
as described in the treatment of talipes. Massage and muscle 
training are required in the after-treatment. If the deformity is 
complicated by defective muscular development and limited joint 
motion massage and passive manipulation may be required for 
years. Complete recovery is unusual. 

In slighter cases of radial club-hand, due to defective develop- 
ment, it may be possible by manipulation and tenotomy to replace 



Fig. 282. 




Congenital absence of radius and the bones of the thumb. (Weigel.) 

the hand in its normal position, but this is unusual. As a rule, 
an operation on the ulna will be necessary, together with 
division of the contracted tissues. Sayre 1 removed a portion of 
the carpus and implanted the head of the ulna at the point of 
resection. McCurdy 2 sawed through the ulna, leaving the 
extremity in relation to the carpus and sutured the proximal 
fragment and the semilunar bone to one another. Thomson 9 
replaced the hand by subcutaneous tenotomy and by the removal 
of a cuneiform section of bone from the lower end of the ulna. 



1 Transactions of the American Orthopedic Association, vol. vi. 
> Ibid., vol. viii. ■ Ibid., vol. ix. 

31 



182 



oirruori:i)ic sviiukry. 



Pig. 288. 



The operation of splitting the ulna into an ulnar and radial 
portion and implanting the carpus between the two has been 
performed by Bardenhauer. 1 The immediate effect of the various 

operative procedures was favor- 
able, but no final results have 
been reported. 

In any event some form of 
apparatus must be used during 
childhood at least, to support 
the hand, whether the operation 
has been successful or not ; and 
at best the arm will be short 
and the thumbless hand weak 
as compared with its fellow. 

Congenital Contraction of 
the Fingers. 

The most common form of 
congenital contraction is that of 
the little finger (hammer finger) 
of one or both hands. This is 
semiflexed and extension is 
checked by what appears to be 
a congenital shortening of all 
the soft parts on the flexor 
side. In other instances several 
fingers may be similarly af- 
fected. 

Treatment. If treatment by 
manipulation and splinting is 
begun early the deformity may 
be overcome by lengthening 
the contracted tissues. In later life the prospect of perfect cure 
by any method of treatment is slight, because of the strong ten- 
dency to recontraction after the finger has been straightened. 

Webbed Fingers. 

In the most common form of this deformity two or more 
fingers are joined by skin and fibrous tissue to the first phalangeal 
joints, l>nt sometimes throughout the entire length of the fingers. 




enital club-hands, showing the short 
and deformed forearms, also bow-legs. (Gib- 
ney.) 



Verband. der deutsch. Gesells. f. Chir., 23 Kong., 1894. 



DEFORMITIES OF THE UPPER EXTREMITY. 483 

In other instances the web may be thicker, containing muscular 
fibres from the apposed parts, and, occasionally, the bones of the 
two fingers may be joined to one another, even to the finger-nails. 

Etiology. The cause of the deformity is arrest of develop- 
ment before the fingers have been separated from one another ; 
thus the thumb, which is differentiated from the other parts of 
the hand as early as the seventy-fifth day of intra-uterine life, is 
rarely involved, as compared with the fingers, which are separated 
from one another at a later period. 

Treatment. In all but the extreme grades of deformity the 
fiugers may be separated from one another ; operative treatment 
being conducted according to the rules of plastic surgery. 

Congenital Displacements of the Phalanges and Distortions 
of the Fingers. 

These deformities are not particularly uncommon. They 
should be treated by manipulation and by splinting at as early 
a period as is practicable. Other congenital deformities and 
malformations of the hand do not call for extended comment. 

Trigger Finger. 

Synonyms. Jerking finger, snapping finger. 

This affection was first described by Nelaton under the title 
" Doigt a Ressort." On extending the closed hand one finger 
remains flexed. If the flexion is overcome by greater muscular 
effort or by passive force the finger flies back to complete exten- 
sion with a sudden snap or jerk ; hence the name. In well- 
marked cases the same difficulty and the subsequent snap is 
i ucperienced in flexing the finger. The middle and ring fingers 
are more often affected, but sometimes the thumb or the fifth 
finger may be involved. 

The patient usually complains somewhat of stiffness and pain 
in the finger, but the interference with its function is the prin- 
cipal -yrn ] (torn. 

Etiology. The usual explanation of the disability i< inter- 
ference witli the motion of the tendon in its fibrous sheath, either 
because of a reduction of its calibre due to injury or inflammation, 
or to an enlargement or irregularity of the tendon itself. In 
most instances the obstruction appears to be in the neighborhood 
of the metatarsophalangeal joint. 

'I be duration of the affection is indefinite. 



is l ORTHOPEDIC SURGERY. ■ 

Treatment. If the obstruction appears to be of inflammatory 
or traumatic origin it may be treated by splinting and later by 
massage. In confirmed cases the tendon and the sheath may be 
explored in the hope of finding and removing the obstruction. 1 

Mallet Finger. 

Synonym. Drop-finger. 

This is caused usually by a blow upon the terminal phalanx, 
which ruptures or weakens the attachment of the extensor tendon 
at the base of the phalanx so that it is habitually flexed some- 
times nearly to a right angle. 

The treatment must be by incision and reattachment of the 
tendon to the periosteum. 

" Baseball finger " is the reverse displacement of the terminal 
phalanx which is dislocated backward, forming a bayonet-like 
deformity. There is often, in addition, injury of the base of the 
phalanx that causes subsequent irregular hypertrophy. 

If reposition is impossible open incision may be employed to 
correct the deformity. 

Dupuytren's Contraction. 

Dupuytren's contraction is a deformity of the hand caused by 
contraction of a part of the palmar fascia and of its prolongations 
to one or more of the fingers. The fingers are flexed as a conse- 
quence to a greater or less degree, and in advanced cases they 
may be drawn to close contact with the palm. The ring finger 
is most often primarily affected, but, as a rule, two or more 
fingers are somewhat involved in the contraction. 

In a large proportion of the cases both hands are affected, 
but not as a rule simultaneously, the contraction beginning in the 
second hand several years after the deformity in the first. 

Pathology. The characteristics of the deformity are explained 
by the anatomy of the palmar fascia. This consists of a strong 
central portion, and two thinner lateral parts that cover the 
muscles of tin- thumb and little finger. It is made up of longi- 
tudinal fibn- continuous with the tendon of the palmaris longus, 
and the annular ligament. It divides into four processes that 
are attached t<» the digital sheaths, to the integument at the clefts 
of the angers, and to the superficial transverse ligament. Pro- 

i The bibliography is large. More recent articles are those of Jamiu, Cent. f. Chir., June 
6, 1896, who reports thirty-one cases, and A. Necker, Beitriige zur klin. Chir., B. x. p. 469. 



DEFORMITIES OF THE UPPER EXTREMITY. 485 

longations of the fascia pass along the lateral aspect of the fingers 
and are attached to the periosteum and to the tendon sheaths of 
the first and second phalanges. 

The cause of the contraction appears to be a chronic plastic 
inflammation of a part of the fascia, which becomes hypertrophied 
and finally contracts, drawing the finger toward the palm in the 
manner described. 

Etiology. The etiology is uncertain. 

The contraction is much more common in men than in women, 
and it is practically confined to middle and later life. It is 
claimed that the deformity is more common among those who 
are subject to gout or rheumatism. It appears, also, to be an 
hereditary affection in certain instances. Injury or irritation of 
the palmar tissues, incident to certain occupations, would seem 
to explain the disproportionate liability of the sexes to the 
affection. 

Symptoms. The first symptom is usually the deformity ; the 
patient finds it impossible to completely extend one or more of 
the fingers ; the tissues about the base of the finger seem stiff, 
and when it is forcibly extended a hard, elevated cord may be 
felt extending from about the centre of the palm to the second 
phalanx, most prominent at the metacarpophalangeal articulation. 

To this the skin is adherent, and as the contraction increases 
it ie thrown into elevated ridges. Later other bands appear if 
the contraction affects, as it usually does, other portions of the 
fascia. In many instances no pain is experienced unless the 
contracted fascia is forcibly stretched or is pressed upon. In 
other cases complaint is made of neuralgic pain in the hand and 
even in the arm and back. Occasionally the first symptom to 
attract attention may be a sensitive nodule in the skin at the 
base of the finger. 

The contraction usually increases slowly until the finger that 
ifl most affected is drawn to the palm. 

Treatment. The deformity may be overcome in part by 
multiple division of the contracted bands from the finger to the 
palm, but complete removal of the contracted fascia is preferable 
if it be possible. The finger i- then supported in an attitude 
of slight flexion until the circulation is adjusted to the new 
position. 



CHAPTER XIV. 

CONGENITAL AND ACQUIRED AFFECTIONS LEADING TO 
GENERAL DISTORTIONS. 

Rhachitis. 

Synonym. Rickets. 

Rhachitis is a constitutional disease of infancy caused by 
defective nutrition, of which the most marked effect is distortion 
of the bones. 

Etiology. The predisposing cause is constitutional weakness. 
This may be inherited or it may be the direct effect of illness, 
but most often it is the result of improper hygienic surroundings, 
particularly lack of sunlight, damp rooms, overcrowding, and 
defective ventilation. The direct cause of the disease is im- 
proper nourishment. In most instances this is due to the substi- 
tution of artificial food for the mother's milk, in others to 
improper diet after the infant is weaned ; in rare cases it may be 
the result of prolonged lactation, or it may be caused by the 
defective quality of the mother's milk. The disease, therefore, 
begins usually between the ages of six and eighteen months, 
although it is by no means confined to these limits. In most 
instances improper surroundings and improper nourishment are 
combined in the causation of the disease ; thus rhachitis is rela- 
tively common in large cities. At the Hospital for Ruptured 
and ('rippled the most extreme cases are observed among the 
Italian and the colored children. The former are usually nursed, 
but arc improperly fed after weaning, while the latter, if nursed 
at all, are usually allowed a mixed diet even during the early 
months of life. 

Pathology. The manifestations of a disease dependent upon 
impaired nutrition are, of course, general in character. In 
rhachitis there is a mild degree of anaemia, and a general weak- 
ness and relaxation <>r the voluntary and involuntary muscles. 
As a nsult the circulation is impaired and the power of assimila- 
tion i- diminished; thus congestion and enlargement of the 
internal organs, Intestinal catarrh, bronchitis, and the like are 
common accompaniments of the disease. The most marked and 
characteristic changes are found in the bones ; these consist in 



AFFECTIONS LEADING TO GENERAL DISTORTIONS. 487 

a diminution of the earthy substances and in overgrowth of 
osteoid tissue. 

" The essential features of the morbid processes are, first, an 
exaggeration of the processes immediately preparatory to the 
development of true bone ; secondly, an imperfect conversion of 
this preparatory tissue into true bone ; and, thirdly, a great 
irregularity of the whole process." (Erichsen.) 

On section of rhachitic bone it will be noted that the perios- 
teum is increased in thickness, and is more or less adherent to 
the underlying softened and spongy tissue. The medullary canal 
is enlarged, and its contents are abnormally vascular. The 
epiphyseal cartilage, normally a thin, bluish line, is much increased 
in thickness. It appears to be swollen and infiltrated, and it has 
lost its former translucency. Microscopic examination at this 
point, where growth is most active, shows marked irregularity 
in size and shape of the columns of cartilage cells ; the zone of 
calcification is lacking or is ill-defined, and masses of cartilage 
cells are found unchanged in what should be the area of true 
bone. The same irregularity of line and shape is observed in 
the medullary spaces of the newly-formed osteoid tissue. 

A- a direct result of the changes that have been described, the 
epiphyseal junctions are enlarged and the shafts of the bones are 
thickened by the formation of osteoid tissue beneath the perios- 
teum. The indirect effects of the disease, and of the weakness 
that it causes, are deformities, the nature of which will be indi- 
cated under the heading of symptoms. The stage of weakness 
is followed by that of repair, which sometimes goes on with 
great rapidity ; the softened bones become abnormally hard, 
" eburnated," and premature solidification at the epiphyseal 
junctions may be one of the remote results of the disease that 
accounts in part for the dwarfing of the stature, observed as one 
of the final results of severe rhachitis. 

Symptoms. As the disease is the effect of imperfect assimila- 
tion it- more pronounced symptoms are preceded by those of 
indigestion, such as flatulence, constipation, and the like. Pro- 
fuse perspiration, especially about the bead, and restlessn< 
night are common symptoms. Teething is often delayed or is 
irregular. The infant is slow in its movements, and makes little 
effort to stand or to walk at the usual time, and if the disease is 
active the affected parts may be sensitive to pressure. 

Deformities. Tie' deformities are in pari Hue to the direcl effect 
of the disease. One of the earliest and mosi constant evidences 



488 ORTHOPEDIC SURGER Y. 

of rhachitis is the enlargement about the epiphyses, an enlarge- 
ment caused in part by the direct hypertrophy and in part by 
pressure upon the softened tissues. The enlargements at the 
junctions of the ribs and the costal cartilages, the rhachitic rosary, 
and at the wrists and ankles, double joints, are almost invariably 
present in well-marked cases. The more general distortions are 
in part the effect of atmospheric pressure, in part the effect of 
the force of gravity and habitual postures, and in some instances 
muscular action or injury may deform the softened bones. These 
deformities differ greatly according to the time of onset of the 
disease, and with its duration and severity. The head may be 
long and oblong in shape, or rectangular, caput qnadratum, and 
it sometimes presents prominences in the frontal and parietal 
regions due to thickening of the bone, and on the posterior 
aspect depressed and softened areas, craniotabes. The fontanelles 
are abnormally large, and they may remain open long after the 
usual time of closure. 

The thorax is compressed from side to side, the compression 
being most marked in the middle region, where the ribs have the 
longest cartilages and the least direct support. As secondary 
results the back of the thorax is flattened and the sternum is thrust 
forward, forming the pigeon breast The lower ribs are everted 
to accommodate the distended abdomen, potbelly. In well- 
marked cases the rhachitic chest presents two distinct grooves, 
one transverse in the axillary line, Harrison's groove, and the 
other passing upward by the side of the rhachitic rosary. These 
deformities are in great degree caused by atmospheric pressure, 
but they are increased if the child assumes the sitting posture 
habitually. In this attitude the body is inclined forward, the 
clavicles are distorted, and the spine is bent into a more or less 
rigid posterior curve, most marked in the lower dorsal and 
lumbar regions, the rhachitic kyphosis. Less often there may be a 
lateral deviation or scoliosis. 

The arms may be distorted by the efforts of the child to sup- 
port the body in the sitting posture, or by active exertion, as in 
creeping (Fig. 284). Occasionally the deformities may be local- 
ized at the elbows, and sufficiently marked to merit the name 
cubitus varus or valgu8 t corresponding to genu valgum or varum ; 
or the principal distortion may be a dorsal convexity of the lower 
extremity of the radius. 

The bones of the lower extremities are often distorted, primarily 
by the habitual postures assumed in sitting or creeping, and these 



AFFECTIONS LEADING TO GENERAL DISTORTIONS. 



489 



deformities are usually exaggerated when the erect attitude is 
assumed. In some instances it would appear that the femoral 
necks are twisted backward somewhat ; this distortion may 
explain in part the limitation of inward rotation that is some- 
times observed in rhachitic children. Depression of the femoral 
neck (coxa vara) may be present also, although this deformity 
does not, as a rule, attract attention until a much later period of 
life. The changes in the pelvis are of special interest to the 
obstetrician. These are essentially an increase in the sacrover- 



FlG. 284. 




General rhachitic deformities, showing distortions of the arms and legs 
induced by posture. 



tebral prominence, due to the forward and downward displace- 
ment of the sacrum, an abnormal expansion of the ilia, caused by 
pressure of the abdominal contents, and, in some instances, a 
decrease of the lateral diameter, an effect of the pressure of the 
femora upon the yielding bone. 

In the milder type of rhachitis in older children who walk, the 
deformities are often confined to the trunk and lower extremities. 
In such cases, in addition to the changes in the bones, there is 
usually a prominent abdomen and increased lordosis, combined 



490 ORTHOPEDIC SURG$R Y. 

with slight habitual flexion of the thighs and lower legs, the 
rhachitic attitude. 

If the disease is of sudden onset and is severe and general in 
its manifestations, it may be accompanied by pain, by sensitive- 
ness of the affected bones, and by such weakness of the lower 
extremities as may simulate paralysis, rhachitic pseudoparalysis. 
It is probable, however, that the cases in which the pain is 
extreme, " acute rhachitis," are, in reality, scurvy or scurvy and 
rhachitis combined, scurvy rickets so-called. 

Rhachitis, as described, is the type ordinarily seen in hospital 
practice, and its manifestations are unmistakable. In its milder 
form it is not particularly uncommon among the children of the 
well-to-do, whose hygienic surroundings are good. In such 
cases the most marked symptom is weakness. The child is 
often fat and well developed, although, as a rule, pale. The 
abdomen is somewhat enlarged and slight prominences at the 
epiphyseal junctions, particularly at the wrists, may be made out. 
The legs appear small in proportion to the body, and the liga- 
ments are lax, so that if the child stands the feet are flat and 
assume the attitude of valgus. In this class, in which the child 
is said to have weak ankles, knock-knee is common. 

The most common symptom of rhachitis of the mild type is the 
failure of the child to attempt to walk at the usual time, about 
sixteen months. If a child who is not ill and who has not 
suffered from exhausting disease does not walk at two years of 
age it is probably rhachitic. 

Prognosis. The duration of the progressive stage of rhachitis 
depends, of course, upon the age of the patient and upon the treat- 
ment. In cases that are untreated and in which the predisposing 
causes continue, the period of repair may be delayed for several 
years or longer, as shown by the fact that the child makes little 
effort to stand. But, in most instances, the rhachitic child begins 
to walk at some time during the third year, and at this time the 
deformities of the lower extremity, knock-knee, bow-leg, flat-foot, 
and the like usually develop or become aggravated, while those 
of the upper extremity may become less noticeable. 

The deformities of rhachitis tend to disappear or to become 
less marked with growth ; the concavities of the distorted shafts 
are filled by accretions of periosteal bone, which is again absorbed 
from the interior as the medullary canal straightens itself. The 
thickened diaphyses and enlarged epiphyses become more sym- 
metrical under the influences of rapid growth and increased func- 



AFFECTIONS LEADING TO GENERAL DISTORTIONS. 491 

tioiial activity, but traces of severe rhachitis always remain, and 
many of the more noticeable and permanent distortions of the 
trunk and of the lower extremities are due to this cause. 

The prognosis as to the outgrowth of rhachitic deformities 
depends upon the duration and the severity of the disease and 
upon the function of the deformed part. Rhachitic distortions 
of the arms almost always disappear. The rhachitic chest is 
rarely seen in the adolescent or adult. The rhachitic kyphosis 
is corrected or modified when the erect posture is assumed, but 
rhachitic scoliosis, on the other hand, usually increases with the 
growth. Distortions of the lower extremities may occasionally 
entirely disappear, and in most cases they are less marked in the 
adult than in the child. Stunting of the growth is a constant 
effect of severe and prolonged rhachitis ; it depends in part upon 
the arrest of development during the active stage of disease and 
in part upon the changes in the bones that cause premature 
consolidation at the epiphyses. 

Treatment. The treatment of rhachitis consists essentially in 
a reversal of the conditions under which it developed. It is, 
therefore, dietetic, hygienic, and medicinal. Deformity, the 
effect of the disease, may be prevented by guarding the weakened 
bones from overstrain, and it may be remedied, if it be present, 
by manipulation or by mechanical or by operative treatment. 

The more detailed treatment of rhachitis may be found in 
works on Pediatrics. In general, the diet in the cases developing 
in early infancy should be of milk, especially modified according 
to the need of the patient. At a later time, corresponding to the 
normal period of weaning, the diet should be largely animal, to 
the exclusion of starchy food, cream and fresh butter being espe- 
cially valuable. 

The patient, protected by proper woollen underclothing, should 
pass as much time as possible in the open air, and should sleep 
in a well-ventilated room. Daily salt baths are recommended 
for older children, and regular massage of the extremities and of 
the abdomen should be employed. Medicinal treatment is of 
secondary importance. The bowels should be regulated and 
digestion should be aided by proper remedies. For anaemia, 
which is usually present, the syrup of the iodide of iron is of 
value ; cod-liver oil serves both as a food and medicine, when it 
is readily assimilated. It is unlikely that any drug lias a very 
direct influence on the disease. Phosphorus in doses of -., ,', „ to 
yi^ of a grain is often given, and is supposed to lessen the 



492 oirruoPEDic surgery. 

abnormal congestion of the bones, while the deficiency of lime 
salts may be supplied possibly by the administration of lime in 
some form, the syrup of the lactophosphate of lime being a 
favorite prescription. 

The prevention of deformity, other than by the means already 
enumerated, consists in preventing habitual postures that predis- 
pose to deformity, and in daily massage and manipulative cor- 
rection of incipient distortions. Young infants and those whose 
bones are especially vulnerable should spend much of the time 
in the reclining posture. The Bradford frame or similar appli- 
ance is especially useful in the treatment of this class of cases. 
The treatment of the more advanced deformities, by support or 
by operation, is described elsewhere. 

"Late Rickets." 

Late rickets is, as the name implies, an affection presenting 
all the characteristics of the common infantile form. This, in 
rare instances, appears in later childhood or even in adolescence ; 
in some cases the affection appears to be a continuation or 
recrudescence of the infantile form ; in others no history of a 
preceding affectiou can be obtained. 1 

By many writers the term late rickets is improperly used to 
explain the deformities of adolescence, genu valgum, coxa vara, 
and the like, although none of the distinctive signs of the affec- 
tion may be present. Local rickets is less objectionable as 
applied to the same class of cases. 

Chondrodystrophia. 

Synonyms. Fcetal rhachitis, achondroplasia. 

( ases that present the signs of what appears to be severe 
general rhachitis at birth are not especially uncommon. The 
trunk is disproportionately long as compared to the stunted 
limbs ; the head is large, the chest presents a pigeon-like distor- 
tion, and the epiphyses appear to be generally enlarged. In 
some instances the back is curved into a rigid kyphosis, or scoliosis 
and restricted motion or apparent fixation of many of the joints 
may be present. 

Etiology and Pathology. These cases were formerly sup- 
posed to be instances of intra-uterine rhachitis ; chondrodystrophia 

i Drewitt. Transactions of the London Pathological Society, 1881, vol. xxxii. Clutton, 
St. Thomas' Hospital Reports, 1884, vol. xiv. 



AFFECTIONS LEADING TO GENERAL DISTORTIONS. 493 

is not, however, the result of a disturbance of nutrition ; it is due 
apparently to a congenital defect in the bones themselves or rather 
of the original cartilage. Rhachitis is characterized by hyper- 
trophy of the epiphyseal cartilages and by delayed ossification. 
In chondrodystrophia, on the contrary, there is atrophy of the 
epiphyseal cartilages and abnormal rapidity of ossification. On 
section of a bone the shaft is seen to be thickened and stunted, 

Fig. 285. 




Chondrodystrophia of slight degree, contrasted with ordinary rhachitis, in sisters. 1. Chon- 
drodystrophia. Broad, short, very flexible hands; trunk disproportionately long; knock- 
knees. Age, five and a half years ; height, 30^ inches ; normal height, 40 inches. 2. Rha- 
chitis, bow-legs ; age, four years ; height, 323^ inches ; normal height, 36 inches. 



the epiphyses are enlarged also, and these hypertrophied and 
prematurely ossified segment- may overhang the diminutive car- 
tilage that intervenes. 

Chondrodystrophia, <>r an affection resembling it, is sometimes 
Fig. 285) in a very mild form ; the appearance of the child 



jo i ORTHOPEDIC SURGERY. 

suggests rhachitis, but the stunting of the growth is greater than 
is ever the result of rhachitis of corresponding severity. 

CRETINISM. Cretinism may cause a similar dwarfing of the 
stature, and cretinism may be combined with chondrodystrophia, 
but in most instances the symptoms of mental deficiency that 
accompany cretinism are lacking in this affection. 

Treatment. The treatment of so-called foetal rhachitis con- 
sists in regular massage and manipulation of the distorted parts 
and of the anchylosed joints. This treatment may extend over 
several years, during which the limbs and back must be protected. 

Rest on the Bradford frame during the period of active treat- 
ment is advisable. If congenital cretinism is suspected the 
administration of thyroid extract would be indicated. 

Prognosis. By persistent treatment the range of motion in 
the stiffened joints may be regained, but the prognosis as to 
growth is bad. The patients present in later years the abnor- 
mally long trunk and stunted extremities that were present at 
birth. 

Infantile Scorbutus. 

Synonyms. Scurvy, scurvy rickets. 

Scurvy in infancy, as at other periods of life, is a constitutional 
disease dependent upon impaired nutrition, caused apparently by 
the deprivation of proper food. The disease was originally 
described by Smith and Barlow as scurvy rickets, but it may, 
and often does, occur independently of the latter affection. 

Pathology. The pathological changes most often found in 
cases of the advanced type are hemorrhages beneath the mucous 
membranes and the periosteum. Separation of the epiphyses 
may occur. 

Symptoms. The disease is most often observed in bottle-fed 
infants from six to eighteen months of age. In some instances the 
patients are evidently ill-nourished, but in others they may appear 
to be in good condition. The early symptoms resemble rheu- 
matism. The child shows evidences of discomfort when certain 
joints, usually <»f the lower extremity, are moved, and as the 
disease progresses it may scream whenever it is turned or lifted. 
The painful joints are sensitive to pressure and they may be 
somewhat enlarged, but local heat and redness, as well as fever, 
are, as a rule, absent After dentition the gums may be swollen 
and spongy, and hemorrhages into the skin or beneath the mucous 
membranes may occur. In extreme cases the swelling about a 



AFFECTIONS LEADING TO GENERAL DISTORTIONS. 495 

joint due to effusion of blood and accompanied, it may be, by 
separation of the epiphysis may be mistaken for the symptoms 
of infectious epiphysitis or even for sarcoma. 

Treatment. The treatment consists primarily in the regula- 
tion of the diet, particularly in the substitution cf fresh milk, 
properly modified, for the patent food or sterilized milk that 
may have been employed. This should be supplemented by 
orauge juice, or that of other fresh fruit. The change of diet 
usually relieves the symptoms. During the painful stage of the 
disease complete rest in the horizontal position on a pillow or 
frame may be indicated ; later, massage of the limbs and back 
may be of service in improving the nutrition, and remedying 
slight deformity. 

Fragilitas Ossium. 

Synonym. Idiopathic osteopsathyrosis. 

Idiopathic fragility or osteopsathyrosis is of congenital origin. 
The bones appear to be weak simply because of a failure in the 
formation of periosteal bone. In such cases there may be dis- 
tortions at birth, apparently caused by intra-uterine fractures, 
and in after-life fracture may follow the slightest accident or even 
sudden motion. Blanchard 1 has reported a case in which there 
were seventy distinct fractures between the ages of two months 
and twenty-seven years. A similar case was for many years 
under treatment in the Hospital for Ruptured and Crippled. 
For a part of the time the trunk and legs were inclosed in a 
plaster-of-Paris casing to prevent the fractures that followed even 
ordinary movements. At the age of fourteen the strength of the 
bones had increased sufficiently to enable the patient to walk 
about with the support of braces, but he was, in stature, about 
the size of a child of seven years. 

Fractures in this class of cases are attended with but little 
pain. They unite slowly with but a small callus. It is prac- 
tically impossible to prevent a certain amount of deformity. 
With advancing years the liability to fracture may diminish, 
but, as a rule, the patient is disabled and dwarfed in stature. 

The treatment is protective. Massage is of some service in 
improving Local nutrition. Medication is of little avail. 2 

There are many other conditions that cause local or general 

1 Transactions American Orthoj>e6!ic Association, vol vi. 

2 Porak. Bull, ct M.'m. de la Boc. Obrt. et Gyn. d« Paris, i-i". Balretti, Beitr. zur Path. 
Anat. und Ally. Path.. 1894, Bd. xvl. 



l!Uj ORTHOPEDIC SURGERY. 

fragility of the bones and thus an inereased liability to fracture. 
For example, the weakness of old age, sometimes called senile 
rickets ; the atrophy caused by disuse incidental to chronic joint 
disease, or the weakness that may be caused by certain diseases of 
the nervous system. In other instances the weakening may be 
the direct result of disease, as, for example, osteomalacia or 
rhachitis. (See Atrophy of Bone, page 241.) 

Osteomalacia. 

Synonym. Mollitis ossium. 

Osteomalacia is a disease of an inflammatory nature, charac- 
terized by an absorption of the earthy substances (decalcification) 
of the bones and by deformity. The disease is one of adult life. 

Fig. 286. 




Osteomalacia in a child. 



It i- far more common among females than males, and pregnancy, 
in about half of the cases that have been reported, seemed to be 
the exciting cause. The disease usually begins insidiously. The 
symptom- are pain on motion, referred to the pelvis and to the 



AFFECTIOXS LEADIXG TO GENERAL DISTORTIOXS. 497 

thighs. This is supposed to be of rheumatic origin until the 
character of the affection is made evident by the weakness of the 
limbs and by the deformities. These deformities are of greater 
interest to the obstetrician than to the surgeon, for when the 
affection complicates pregnancy the distortion of the pelvis may 
be so great as to prevent normal delivery. 

Osteomalacia in Childhood. Three cases of osteomalacia in 
childhood have been reported by Siegert, 1 and one case has come 
under my observation. The patient, one of twelve living chil- 
dren of healthy parents, was nursed by his mother for the usual 
period, and until the age of four years he appeared to be perfectly 
healthy. At this time, without known cause, general weakness 
became apparent, and at the same time deformities of the lower 



Fig. 287. 




Osteitis deformans in a female seventy-tbree years of age. (Lunn.-) 

extremities developed. At the age of six years he was unable to 
stand. At the present time the condition of the patient, now 
nine year- of age, is shown in Fig. 286. There is no evidence 
of rhachitis or of paralysis. The patient has never suffered 
from pain or discomfort. The lower extremities are somewhat 
atrophied from disuse, the bones are abnormally flexible and are 
distorted to a moderate degree. The epiphyses are not enlarged 
Fig. 282 . 

Treatment. As the etiology of the affection is unknown, 
the treatment is therefore experimental or symptomatic and 
palliative 

Local Osteomalacia. When deformity of a bone appears and 
increases without apparent cause it is often assumed that a local 
disease — "local rickets or local osteomalacia" — is present. 



.-,. rnf,-d. Wochenschr., November 1. 
-Prince. American Journal of the Medical £ ber, 1902. 



498 



oiminrEDIC SURGERY. 



Local weakness and deformity may be caused by injury or by 
subacute osteomyelitis and the like. If there is a distinct local 
disease that deserves the name of local osteomalacia, its cause has 
not been determined. 

Osteitis Deformans. 

This disease was first described by Paget 1 in 1877. It is a 
chronic inflammatory affection of the bones, characterized by 
hypertrophy and softening. " The bones enlarge, soften, and 
those bearing weight become unnaturally curved and misshapen." 



Fig. 2S8. 



Fig. 289. 





Normal tibia and foot. 



Osteitis deformans. Hyperostosis and decalci- 
fication. (Fitz.) Contrast with Fig. 289. 



Section of an affected bone shows it to be markedly increased 
in size, and somewhat in length, by a combination of rarefying 
and formative osteitis. The inner layers become porous, and at 
the same time new bone is deposited beneath the periosteum. 

The disease appears to be confined to adult life, and it is 

apparently more common among males than females. Of 67 

collected by Packard, Steele, and Kirkbride, 2 61 per cent. 

were in males. Occasionally but a single bone is affected. Such 



« Med. Cbir. Trans., 1S«2, vols. xl. and lxv. 

2 American Journal of the Medical Sciences, November, 1901. 



AFFECTIONS LEADING TO GENERAL DISTORTIONS. 499 

are, in all probability, early cases, for, as a rule, the lesions are 
symmetrical and general in distribution, the bones of the lower 
extremity, the skull, and the spine being more often involved. 
Thus the head progressively increases in size, and the legs become 
bowed. If the spine is affected it bends forward, forming a long, 
more or less rigid kyphosis. 

Aside from the deformities and the characteristic enlargement 
of the bones, the symptoms are not marked. At times complaint 
is made of pain usually supposed to be rheumatic until the char- 
acteristic changes in the bones appear. The disease is extremely 
chronic in its course, and, as a rule, the general health is not 
seriously affected. In several instances sarcoma of bone finally 
caused death many years after the onset of the disease. Its 
etiology is unknown, and its treatment is palliative. 

Secondary Hypertrophic Osteo-arthropathy. 1 

Osteo-arthropathy is an inflammatory disease of the bone char- 
acterized by hypertrophy, clubbing of the fingers, and effusion 
into certain of the joints. The hypertrophy is caused by a 
deposition of layers of bone beneath the periosteum of the meta- 
carpal and metatarsal bones, the phalanges and the distal 
extremities of the adjoining bones of the arms and legs. Less 
often the area of the disease is more extensive, involving the 
femora, the humeri, and the spine even. 

Osteo-arthropathy is usually a complication of pre-existing 
chronic disease, most often of the lungs. The patient first 
DOtices clubbing of the terminal phalanges and hypertrophy of 
the finger-nails, later an increasing enlargement of the wrists and 
ankles and of the hands and feet, accompanied by discomfort, 
sensitiveness to pressure, and often by effusion into the neighbor- 
ing joints, symptoms that would be classed as rheumatic were it 
not for the evident hypertrophy. 

The clubbing of the fingers is due, in part at least, to impair- 
ment of the circulation, and the connection of the disease of the 
- with that of the lunjrs has suggested the theory that it is 
caused by the absorption of toxins, and that its etiology is similar 
t<> the amyloid hypertrophy of the internal organs thai sometimes 
follow- chronic disease of bones and joint- attended by suppuration. 

The treatment is symptomatic, and a- the affection is almost 

1 Marie. Revue M»'dica1e, Paris, 1890, x. i>. l. Bamtmrger, Wiener Klin. Wocta., ' 

^scherhir 



500 ORTHOPEDIC SURGERY. 

always secondary to a graver disease but little is known of its 
outcome. It is certain, however, that the secondary osteo-arthro- 
pathic symptoms become less marked or may even disappear as 
the patient recovers from the original disease of the lungs or 
other organs. The affection is very uncommon in childhood. 
In one characteristic case observed by the writer complete recovery 
followed the cure of Pott's disease and chronic bronchitis, the 
hypertrophied phalanges alone remaining. 1 

Acromegalia. 

This affection is also characterized by progressive enlargement 
of the hands and feet, but it differs from osteo-arthropathy in that 
all the tissues are involved in the hypertrophy. The hypertrophy 
of the bone is limited to the epiphyseal extremities, and is slight 
compared with that of the soft parts. The face is often involved, 
the tissues of the nose, lips, and ears being enlarged and thickened, 
together with the underlying bones, so that the expression is very 
markedly changed. 

Acromegalia is common among those of gigantic stature, the 
local hypertrophy and the gigantism both being due, it is sup- 
posed, to disease of the pituitary gland. 

Diagnosis. The three affections that have been described — 
osteitis deformans, osteo-arthropathy, and acromegalia — are rare 
diseases, and they are of little practical interest to the surgeon 
other than from the standpoint of diagnosis. This might be 
somewhat difficult if the pathological process were confined to a 
single bone or limb, as is sometimes the case in osteitis deformans. 

The essential characteristics of the three diseases may be sum- 
marized as follows : In osteitis deformans the entire bone is 
increased in size and length, and because of the coincident weak- 
ening of its structure it becomes distorted ; the skull is usually 
involved, but the hands and feet are not often affected. It is a 
disease of middle or later life, and there are, as a rule, no symp- 
toms other than those due to the local changes in the bones. 

In osteo-arthropathy the process is an hypertrophy of a slight 
degree, caused by deposition of periosteal bone, especially about 
the distal extremities of the shafts of the bones adjoining the 
hands and feet. It is not often accompanied by the weakness or 
the deformity that is characteristic of the preceding affection ; 
the skull is not usually involved, but the long bones of the hand 

1 Whitman. Pediatrics, February 15, 1899. 



AFFECTIONS LEADING TO GENERAL DISTORTIONS. 501 

and feet are thickened, so that these members are markedly 
increased in size. There is often coincident discomfort and swell- 
ing of the neighboring joints. As a rule, the local affection of 
the bones is secondary to chronic disease of the lungs. 

In acromegalia the marked changes are hypertrophic enlarge- 
ments of the hands and feet in which all the tissues are involved ; 
the hypertrophy of the bones is most marked about the epiphyses, 
the diaphyses remaining unaffected ; thus it differs from the 
preceding disease, in which similar enlargement of the extremities 
occurs. The head is often involved, but the hypertrophy is of 
all the structures of the face, not of the skull, as in osteitis 
deformans. 

The disease appears to be confined to early adult life, and 
it is often preceded or accompanied by symptoms of a general 
nature, headache, mental impairment, and the like. 

The changes in the bones characterizing the affections may be 
easily demonstrated by means of the Roentgen pictures. 



CHAPTER XV. 

CONGENITAL DISLOCATION OF THE HIP AND COXA VARA. 

Congenital Dislocation at the Hip-joint. 

Of all the congenital dislocations, or, perhaps, more properly, 
misplacements, that of the hip-joint is by far the most common 
and the most important. 

Statistics. Congenital dislocation of the hip is much more 
common in females than in males. In 671 cases collected from 



Fig. 290. 




Congenital dislocation of the hip, showing the elongated capsule and the right-angled 
relation of the neck to the shaft of the femur. (William Adams.) 



different sources by Lorenz, 589 (87.8 per cent.) were in females 
and 82 (12.2 percent.) in males. Of 1039 cases seen at the 
Polyclinic in Milan, 867 (83.4 per cent.) were in females, 172 



CONGENITAL DISLOCATION OF HIP AND COXA VARA. 503 

(16.6 per cent.) in males. 1 In 500 cases from the records of the 
Hospital for Euptnred and Crippled, investigated for me by Dr. 
C. P. Flint, 413 (82.6 per cent.) were in females and 87 (17.4 
per cent.) in males. 

The dislocation is more often unilateral than bilateral. In 
Lorenz's series of 671 cases 421 (64.4 per cent.) were single ; 
225 of the right, 196 of the left side. In 245 cases (36.6 per 
cent.) the displacement was bilateral. 

Statistics of Five Hundred Cases of Congenital Dislocation of 
Hip, Recorded at the Hospital for Ruptured and Crippled. 

Per cent. 

Males . . . • 87 17.40 

Females 413 82.60 

500 100.00 

Right hip 135 27.66 

Left hip 218 44.47 

Both 136 27.87 

489 100.00 

Not specified 11 

500 
Males. 

Right hip 25 30 48 

Left hip 32 39.04 

Both 25 30.48 

82 100.00 

Not specified 5 

87 
Females. 

Right hip 110 27.04 

Left hip 186 55.69 

Both Ill 27.27 

407 100.00 

Not specified 6 

413 

The dislocation at the time when the patients are brought for 
treatment is usually posterior, upon the dorsum of the ilium ; in 
other instances it is anterior, and the head of the bone may be 
Celt beneath the anterior superior spine. It is probable, however, 
that the primary displacement is often directly upward, for in 
those cases discovered in infancy this position is common. 

Pathology. The pathological anatomy of the dislocation was 

first clearly demonstrated by Dupuytren in L826, and since 1890, 

when the open operation was first performed, the exact relation 

and the appearances of the different components of the joint have 

described in detail by Hoffa, Lorenz, and other operators. 



i Bernacchi. ZeiU. Orth. Chlr., vol. ii. p. 27: 



504 



ORTHOPEDIC SURGERY. 



Fig. 291. 



The condition of the joint varies with the age of the patient 
and the strain and friction to which the displaced parts have 
been subjected. In early infancy it may be assumed that the 
head of the hone lies in close proximity to what is, in some 
instances, a practically normal acetabulum; in others to one that 
is somewhat rudimentary, often shallow and small, sometimes of 
an oval or of a somewhat triangular shape. The acetabulum is 
covered with normal hyaline cartilage, the ligamentum teres is 
present, and the capsule is of nearly normal structure. At a later 
time, when the joint is exposed at operation at the age of five or 
more years, the capacity of the rudimentary acetabulum may be 
lessened by a deposit of fat and fibrous tissue. As a rule, how- 
ever, it appears to be of fair size and depth. The capsule is 
elongated to accommodate the upward displacement of the femur. 
It is hypertrophied, especially where it covers the upper part of 

the head of the bone, and it 
may be drawn into a shape 
like an hour-glass ; the up- 
per part contains the head 
of the bone ; the anterior wall 
is drawn tightly across the 
acetabulum, forming at its 
upper border a narrow slit- 
like communication, through 
w T hich the ligamentum teres 
passes if it be present (Fig. 
286). The interior of the 
capsule is in part lined with 
synovial membrane, and it 
often contains more synovial 
fluid than is found in the 
normal joint. 

The ligamentum teres, al- 
though probably present at 
birth in a large proportion of 
the cases, becomes attenuated and ribbon-like with the increasing 
elongation of the capsule, and after the age of five years, or at 
the time when the open operation is performed, it is usually absent, 
and far more often in the bilateral than in unilateral cases. 
According to Lorenz, in 52 cases between two and a half and 
five yean it was present in 17 ; in 48 cases beyond the age of 
live y<ar- it was present in but 4. In rare instances it may be 




Congenital dislocation of the hip, showing the 
original and the acquired acetabula. (Lorenz.) 



COXGEXITAL DISLOCATION OF HIP AND COXA VARA. 505 

kvpertrophied. In my own experience the ligament is present 
in a very much larger proportion of the cases, although it is often 
so rudimentary that it might easily be overlooked. 

A shallow secondary acetabulum, formed in part by the direct 
pressure of the head of the bone through the adherent capsule, 
and in part the result of irritation of the periosteum, is usually 
found upon the ilium (Fig. 292), but it is not often of sufficient 
depth to assure a secure support for the head of the femur ; thus 



Fro. 292. 





Congenital dislocation of the hip in adult age, showing the abnormal shape of the ace- 
tabulum, the depressions in the ilium caused by the pressure and friction of the head of the 
femur, and the destructive effect of this pressure and friction upon the femur. (Adams.) 

it- upper margin gradually recedes or two distinct depressions 
may be formed, one above the other. The upper extremity of 
the femur i- usually somewhat atrophied. The neck is often 
shorter than normal, and its angle may be lessened, and in many 
instances it- forward inclination is increased. The head of the 
}><-!)<• may be nearly normal, although usually it is somewhat 
flattened on its inner and under surface, or it may be somewhal 
conical, acorn-like in shape, or again compressed from side to 
side to an almond shape or otherwise distorted. The abnormal- 



506 



ORTHOPEDIC SURGERY. 



iii«-, in part congenital, become more marked with age, and in 
adult specimens the head and neck of the femur may be so 
atrophied and worn away that it has little semblance of normal 
contour ( Fig. 292). 

There are also secondary changes in the bones of the pelvis. 
In unilateral dislocation the pelvis is usually somewhat atrophied 



Fig. 298. 



Fig. 294. 





c£l_J 



Trilateral dislocation, showing the inclination 
of the body toward the shorter leg. 



The same patient before operation, 
showing the abnormal lordosis and rota- 
tion of the pelvis. (See Figs. 320 and 321.) 



oo the affected Bide, and a lateral inclination of the spine may be 
present The final changes in the pelvis caused by the bilateral 
dislocation are more important; its inclination is increased, the 
lumbar Lordosis i- exaggerated, the sacrum is forced forward and 
downward -"that the anteroposterior diameter is lessened ; the 
tuberosities of the ischia are everted and the transverse diameter 
«»f tie- pelvic outlet i- increased. 



CONGENITAL DISLOCATION OF HIP AXD COXA VARA. 507 

The long muscles of the thigh are shortened, while those 
attached about the trochanter are changed in direction and arc 
usually lengthened. There is also a slight general muscular 

O Co 

atrophy that is particularly marked in the gluteal group. 

The changes that have been described are in great degree 
secondary to the displacement. They are in part congenital, in 
part accommodative, and in part due to the influences of attrition 
and injury, to which the abnormal mobility predisposes. Thus, 
as a rule, they become more marked with increasing age, and in 
some of the adult specimens but little resemblance to the normal 
parts remains. 

A- a rule, congenital dislocation of the hip is not accompanied 
by defective development or deformity elsewhere, although cases 
are sometimes seen in which a general laxity of ligaments is 
present or in which the dislocation may be one of a series of 
deformities and malformations. 

Etiology. Xothing positive is known of the etiology of the 
dislocation. In a small proportion of the unilateral cases it may 
be due to violence at birth, but the fact that nearly $5 per cent, 
of the patients are females makes it evident that the primary 
cause can be neither iujury nor disease. 

Hereditary influence can be established in a few instances. 
The writer has examined three female children in a family of 
nine, in each of whom there was dislocation of the left hip, the 
order beiug the third, eighth, and ninth child. Also twins in 
another family, one having single and the other double disloca- 
tion. And in four instances congenital displacement was present 
in the mothers of patient-. 

Of the various theories that have been advanced to account for 
odition, tin- most reasonable seems to be defective develop- 
ment. This defective development may affect the entire acetabu- 
lum, or it may involve only its posterior margin, or the can--' of 
th'- displacement may be an abnormal laxity <»f the capsule that 
predisposes t-- displacement when the thigh i- flexed and ad- 
ducted. 

It i- evident that the defective development may l>*' the cause 

of tin- luxation, or it may !«• an effed of displacement <>r himI- 

•n which in turn may be dm- t<> an abnormal or constrained 
attitude of t!m* foetus. 

The predisposing attitude i- doubtless flexion and adduction of 

■ 1 dislocation at tin- joint i~ relatively frequent 

•iilum !■» -hallow in foetal Iif<\ According to 



508 



ORTHOPEDIC sriiOERY. 



Fig. 295. 



Sainton'- observations, in newborn children it covers but one- 

third of the femur, but at the age of five years it is sufficiently 

deep to contain one-half of it. 

Heusner 1 and Marcwald, from an examination of eighty-five 

foetuses, conclude that the greater liability of females to the 

dislocation is explained by 
the disproportionate laxity 
of the capsule as compared 
with males. 

It is probable that the dis- 
location, in some cases at 
least, is at birth a subluxa- 
tion only, that becomes com- 
plete through muscular ac- 
tion and by the use of the 
limb in standing and walk- 
ing. 

Symptoms. The dis- 
placement does not, as a 
rule, attract attention until 
the child begins to walk, 
although in some cases the 
mother may have noticed a 
peculiar breadth of pelvis, or 
a " lump " on the buttock, 
or a " snapping " about the 
hip-joint, or a peculiar atti- 
tude of the limb before this 
time. 

Unilateral Dislocation. If 
the displacement is of one 
congenital dislocation of both hips, illustrating side, a limp is immediately 

the separation of the thighs, the abnormal breadth , . , . 

Otthi pelvic region, and the prominent trochanters, apparent, which becomes 

more noticeable as the child 
grows older. The limp is peculiar, and its character is ex- 
plains] by its cause ; for the shortened limb, owing to the 
elasticity of the capsule, becomes still shorter when the weight 
falls upon it; thus in walking there is a peculiar lunge of the 
body toward the short side, that has been likened to the motion 
in walking down stairs. In the ordinary form the head of the 




> Zeits. f. Orth. Chir., 1902, Bd. x. H. 4. 



CONGENITAL DISL0CAT10X OF HIP AXD COXA VARA 



509 



femur is displaced upward and backward, aud in compensation 
the pelvis is tilted toward the short limb and its inclination is 
increased ; it is thus twisted downward and forward so that the 
anterior superior spine lies at a lower level and in advance"bf 
that of the opposite side (Figs. 293 and 294). 



RtG. 296. 




Bilateral congenital dislocation of the hip, ihowlog ' 



At an early age the shortening of the Limb, due to the elevation 
«»f the trochanter, is from one-half to three-quarters of ao inch. 
In lat<T childhood the elevation is from one and one-half to two 
inches, and in adult life it may be considerably more. 

•" the displacement ia also shown by a flattenii 
mttock, and usually the elevated and prominent trochanter 



510 ORTHOPEDIC SURGERY. 

may be Been as an abnormal lateral projection, on a level with 
the anterior superior spine, which is, as has been stated, some- 
what tilted downward. 

In childhood motion in the false joint is more free than normal, 
and the abnormal mobility can be demonstrated by alternate 
traction and upward pressure on the limb, but as the femur 
become- larger and the upward displacement increases, the 
mobility is restricted. The range of abduction is much diminished, 
and in extreme cases the limb may become permanently adducted 
and Hexed, thus adding the apparent shortening of adduction to 
that caused by the dislocation (Fig. 297). 

Bilateral Dislocation. When the dislocation is bilateral the 
shortening of the limbs is, as a rule, equal or nearly so, and if, as 

Fig. 297. 



/■ 





Congenital dislocation in an adolescent, illustrating the flexion contraction 
in a well-marked case. 

is usual, both femora are displaced backward, the pelvis is tilted 
forward; thus in compensation "the hollow " of the back is 
increased, the abdomen protrudes, the buttocks are flattened, the 
pelvis appears to be abnormally wide, and the thighs are sep- 
arated by a considerable interval (Figs. 295 and 296). The limp 
characteristic of the single displacement is replaced by an exag- 
gerated waddle, a " sailor gait." 

General Symptoms. In early childhood there are no special 
symptoms other than the limp or the waddle, but as the child 
becomes more active it usually complains of discomfort after 
exertion. It i- easily fatigued, and at times it may suffer actual 
pain. These symptoms are, of course, more marked in the double 
than in the single displacement, because in the latter case the 
normal limb is capable of bearing more than its share of the strain. 



COXGEXITAL DISLOCATIOX OF HIP AND COXA VARA. 511 



Fig. 298. 



The symptoms often increase dnrmg adolescence, but they may 
become less troublesome in adult life, when the head of the bone 
may have found a permanent resting place on the pelvis ; a 
security which is often assured by a corresponding limitation of 
the range of motion. The shortening and the secondary effects 
of the displacement, of course, persist, so that 
the individual is, as compared with the normal 
standard, more or less disabled and deformed. 

The great majority of the patients are 
females, and, because of the less laborious 
occupations and the distinctive dress, the dis- 
ability and its effects are less serious than if 
the displacement were more equally divided 
between the sexes. 

Anterior Dislocation. The symptoms of 
the unilateral anterior dislocation, in which 
the head of the bone lies beneath the anterior 
superior spine, are much less marked than in 
the ordinary form because the relation of the 
pelvis to the femur is nearly normal ; so that 
secondary deformity is slight. The shorten- 
ing is less and the limp is less noticeable 
because the resistance of the tissues attached 
to the anterior superior spine is sufficient to 
assure a relatively secure support. 

In bilateral anterior dislocation the entire 
body is swayed slightly backward, but the 
lumbar lordosis is not increased ; in fact, the 
back is often peculiarly flat. Otherwise the 
symptoms do not differ, except in degree, 
from those of the posterior displacement 
Fig. 298 . 

Supracotyloid Displacement. As lias been 
stated, in early cases the displacement may 
be a form <»f subluxation in which the head Lies bul slightly 
above til*- Dormal position. The same upward displacemenl is 
rionally found in older subjects. The physical signs are 
similar to those of the anterior displacement. 

Diagnosis. The diagnosis offers no difficulty. The hi* 
of the limp or waddle noticed when the child began to walk and 
yet anaccompanied by pain <>r preceded by injury or disease is in 
it-elf sufficiently distinctive. If tie- displacemenl is <>f one side, 



Bilateral anterior con- 
genital dislocation. The 
lordosis is far less marked 
than in the ordinary form. 



512 



<>n riion-mc strgery 



measurement demonstrates the shortening as compared with the 
other limb, a shortening that is explained by the prominence and 
the elevation of the trochanter above Xelaton's line. Traction 
and upward pressure on the leg will demonstrate the abnormal 
mobility of the displaced head ; and finally, if the thigh be flexed 
and adduoted to its extreme limit, the neck and head of the femur 
can be easily distinguished moving under the gluteal muscles 
when the limb is rotated. Thus it may be differentiated from 

Fig. 299. 




Bilateral congenital dislocation of the hip. 

depression of the neck of the femur (coxa vara), in which, although 
the trochanter is elevated, the neck and head of the bone cannot 
be felt, and in which the abnormal mobility, characteristic of the 
dislocation, is absent. Again, coxa vara is almost never a con- 
genital affection; therefore, the history itself would practically 
exclude it. 

rpwanl displacement of the femur not infrequently follows 
infectious epiphysitis or arthritis of infancy or early childhood. 
In such cases a part of the upper extremity of the bone is usually 



COXGEXITAL DISLOCATION OF HIP AXD COXA VARA. 513 



destroyed, so that the* head cannot be distinguished on palpation. 
Although the other physical signs are similar to those of the 
congenital displacement, the scars about the joint show the evi- 
dence of former disease, and the history is almost always available 
for diagnosis. Thus, as a rule, 
such disabilities, as well as trau- 
matic dislocations or other re- 
sults of injury or disease, are 
readily excluded. 

The bilateral dislocation pre- 
sents, of course, the same physi- 
cal signs as the single form ; it is 
even more easily recognized by 
the peculiar appearance and dis- 
tinctive gait of the patient. 

The waddling gait may be 
simulated by that of extreme 
bow-legs, but the hip-joints are, 
in this deformity, normal in ap- 
pearance and function. The 
waddliug of lumbar Pott's dis- 
ease is also somewhat similar, 
but this is an acquired painful 
disease of the spine, in which the 
hip-joints are normal in appear- 
ance and usually so in function. 

Pseudohypertrophic paralysis 
may be mentioned as causing a 
somewhat similar gait and at- 
titude, but here the resemblance 
ceases. 

As has been stated, the diag- 
nosis of congenital dislocation 

can be easily made by physical examination ; the only real diffi- 
culty is experienced in certain dislocations or subluxations of the 
anterior type in which a secure secondary acetabular support has 
formed, and in cases seen in early infancy in which the dislocation 
may be incomplete, but opportunity for such early diagnosis 
is rarely offered. In doubtful cases a Roentgen picture will 
demonstrate the character of the disability (Fig. 299). 

Treatment. Dupuytron, in 1829, after a careful study of the 
anatomy of the deformity, came to the conclusion that it waa not 

33 




Bilateral dislocation in adolescence. This 
patient was practically disabled by pain and 
weakness. 



514 ORTHOPEDIC SURGERY. 

only incurable but that palliation of its effects even was hardly 
attainable ; and for sixty years the statement was generally 
accepted, although cures were attained in all probability by 
Pravaz, of Lyons, 1847, and at a much later time by Paci, of 
Pisa, 1887. 

The term dislocation naturally suggests that cure implies 
replacement and retention of the displaced bone in its proper 
place, and in 1890 Hoffa, now of Berlin, first performed this 
operation with success by opening the joint from behind and 
enlarging the rudimentary acetabulum to a size sufficient to con- 
tain the head of the bone. The details of the operation were 
afterward modified by Lorenz, of Vienna, 1 and at the present 
time the original operation has been to a great extent abandoned 
for bloodless reposition, but to Hoffa belongs the credit for the 
introduction of the modern treatment of this disability. 

The Lorenz Operation of Bloodless Reduction, Retention, 
and Weight Bearing. 

This treatment is based on the experience obtained by the 
open treatment that an acetabulum of fair size is practically 
always present. This acetabulum is not of sufficient capacity to 
retain the head of the femur when the limb is in the normal 
attitude, but it is sufficiently deep to permit of retention when 
the limb is fixed in abduction. 

It has been proved, also, that by traction and leverage the 
head of the femur in most instances can be forced into direct con- 
tact with the rudimentary acetabulum. Once this contact or 
reposition is attained, the limb must be fixed to prevent dis- 
placement, and as soon as possible the patient must stand and 
walk in order that the weight of the body and functional use may 
deepen the rudimentary acetabulum. Meanwhile the distended 
capsule and other tissues contract about the new joint, and the 
muscles become accustomed to their new functions. That the 
acetabulum may be actually enlarged by the presence of the head 
of the femur is proved by the fact that secondary depressions of 
sufficient size to form joints of fair stability are often found upon 
the pelvis in anatomical specimens from older subjects. 

The first step in the operation is to overcome the resistance of 
the tissues, namely, of the capsule and of the long muscles that 

1 Pathologie und Therapie der Angebornen Hoeft Verrenkung, Wien, 1895 ; Ueber heilung 
der Angebornen Hoeftgelenk Verrenkung, Leipzig u. Wien, 1900. 



COXGEXITAL BISLOCATIOX OF HIP AXD COXA VARA. 515 

have become structurally shortened in accommodation to the 
upward displacement of the head of the femur. The second step 
is to reduce the dislocation, or, rather, to force the head of the 
femur over the posterior or upper border of the acetabulum. 
The third is to increase the security of the articulation by 
stretching the anterior border of the capsule. The fourth is to 
fix the parts securely in a plaster bandage. 

The Lorenz Operation. The patient is placed upon a table with 
a thick folded sheet beneath the buttocks. The assistant, stand- 
ing opposite the operator, fixes the pelvis with his hands (Fig. 
301). In some instances better control is assured by pressing 

Fig. 301. 




Reduction of dislocation of the right hip. First step. The operator breaks down the 
resistance offered by the adductors by forcible massage. 

the flexed thigh of the sound side downward against the abdomen, 
as in the Thomas test for flexion in hip disease. 

The operator first flexes the thigh to a right angle with the 
body, then forcibly abducts it, at the same time kneading the 
tense muscles with the ulnar border of the hand, stretching and 
rupturing the fibres until the normal prominence has entirely 
disappeared. The stretching is continued until the limb can be 
forced down to the plane of the body. One next overcomes the 
shortening <>f the tissues on the posterior aspect by flexing the 
liuil). extended at the knee, upon the trunk, gradually forcing it 
downward until the toes may be placed against the patient"- face 



" 



16 



ORTHOPEDIC SURGERY. 



Fig. 302. 




Forcible flexion of the extended limb on the abdomen. Second step in the operation. 

Fig. 303. 




Forcible extension of the thigh. Third step in the operation. 



COXGEXITAL DISLOCATION OF HIP AND COXA IMAM. 517 

(Fig. 302). Paring this manoeuvre the assistant fixes the pelvis 

by holding the extended thigh of the sound side firmly against the 
table. The next step is to overcome the resistance of the tissues 
on the front of the joint. The pelvis is fixed by the assistant. 
The leg is then flexed upon the thigh, and the thigh is forced 
downward behind the plane of the body, or the patient may be 
turned upon the side, as in Fig. 303. After this preliminary 
stretching traction is made upon the limb, and if with slight 
effort the trochanter can be drawn down to Nelaton's line reduc- 
tion is attempted. 

Reduction. The pelvis having been fixed as in the first position, 
the limb is slowly and forcibly abducted over a wedge of wood 
Biiitably padded, the apex of which is placed between the 
trochanter and the pelvis (Fig. 304). As the limb is gradually 

Fig. 304. 




Reposition. The thigh is forcibly abducted over the padded wedge. Fourth step in the 
operation. The wedge is of hard wood of the following dimensions : length, 9 l / 2 inches ; 
height, 3% inches ; base, 3 inches. 

forced downward to and behind the plane of the body, the head 
of the femur is forced upward until it finally snaps over the pos- 
terior border of the acetabulum. Reduction is usually accompanied 
by a distinct jar, and often by an audible thud. It is also indi- 
cated by tension upon the posterior muscles <>f the thigh which 
causes fixed flexion of the leg. An effort i- now made to increase 

apacity of the joint. The patient i- turned upon the sound 
-\>\>- and the pelvis, having been fixed by the assistant, the 
operator draw- the thigh over and over again behind the plane 
of the body, and at the same time rotates it from side to Bide. 
The security <>f the reposition is then determined. One testa 
ly the stability or depth of the superior margin «»f the 

bulum by reducing the abduction ; of the posterior margin by 
Lifting tie- thigh ventral ward, and in a similar manner the Inferior 

er. l'| this examination the prognosis is made; if the 



518 



ORTHOPEDIC SURGERY. 



stability allows an approximation to the normal position before 
displacement occurs the prognosis is good. If, on the other hand, 
the margins of the acetabulum are so ill-formed that displacement 
occurs vcrv easily the prognosis is bad. 

The operation is varied somewhat in certain instances. If 
after the stretching, the trochanter still remains above Nekton's 
Line, one attempts to overcome the remaining resistance by direct 
traction in the line of the body. Counter-resistance is furnished 
by a folded sheet passed between the thighs about the perineum, 
the two ends of which are tied about a corner of the table. Trac- 
tion on the limb is made by one or two assistants while the 



Fig. 305. 




Reposition in young subjects, the thumb being used as the fulcrum to reduce the left hip. 

operator supports the pelvis and presses downward and inward 
upon the trochanter. Occasionally reposition is effected during 
this manoeuvre — that is, the head is drawn over the superior 
instead of the posterior border of the acetabulum. 

Preliminary Traction. In the treatment of older patients or 
of more resistant cases preliminary traction in bed is advisable. 
The traction must be considerable, and heavy weights, if possible 
up to forty pounds or more, should be employed for two or more 
weeks. This is of great advantage. 

Reduction in Young Subjects. In younger subjects the wedge is 
not necessary, bul the thumb of the operator may be used as a 



CONGENITAL DISLOCATION OF HIP AND COXA VARA. 519 

fulcrum beneath the trochanter to lift and push the head upward 
while the limb is abducted. Iu this class of cases much less 
force is required in the preliminary stretching (Fig. 305). 

After reposition has been accomplished and when the greatest 
possible stability is assured by abducting the thigh again and 
again and forcibly rotating it from side to side to stretch the con- 
tracted anterior wall of the capsule and by extending the leg upon 
the thigh, to thoroughly overcome the resistance of the hamstring 
muscles the plaster bandage is applied. A close-fitting stock- 
inette shirt, of which one-half has been cut and sewed to cover 
the limb, as a drawer, is drawn on over the limb, threaded as it 
were, with a long bandage, the " scratcher." The patient is 
then placed upon the pelvic rest and the limb is held in the 

Fig. 306. 




The position in which the limb is held when the plaster bandage is applied. 

position of greatest stability at a right angle with the trunk and 
lying behind the plane of the body. The pelvis and thigh are 
thoroughly and thickly covered with layers of sheet-wadding or 
cotton. This is bandaged firmly with cotton flannel, t<> assure a 
Blight elastic compression (Fig. 30< 

The plaster spies i- then applied. This should be thick and 
firm, at least a dozen and oftentimes many more <>f the ordinary 
-i/«- being used by Lorenz. These bandages are drawn snugly 
around the pelvis and thigh by a -eric- of reverses and figure-of- 
eight turns, clasping tin- iliac crests ami thoroughly covering 

in the buttock, Tie- support i- CUl away, to aliow motion at the 

knee-joint and the ends of the shirting are then drawn smoothly 
over th<- bandage and are sewed to on.- another I '. 9. 307 and 



520 



ORTHOPEDIC SURGERY. 



The operation is usually followed by swelling and discoloration 
in the adductor region and more or less pain, especially when 
the leg is moved. This soon passes away, usually during the 
first or second week, and the child is then encouraged to stand. 
As it is only with extreme difficulty that the foot on the operated 
side can be brought to the floor, a cork-soled shoe from one and 
a half to three inches in height is usually worn to facilitate 
walking. 

As has been stated, walking is encouraged on the theory that 
weight bearing and the stimulation of functional activity will 
increase the stability of the joint by deepening the acetabulum 
and accentuating its boundaries. In most instances the range 



Fig. 307. 




The plaster bandage as applied by Lorenz, illustrating the extreme thickness of the 
pelvic portion and discoloration of the adductor region. 



of extension at the knee is for a time somewhat restricted. This 
restriction is overcome by passive force and by the voluntary 
effort of the patient. The first bandage is allowed to remain in 
place for from six to eight months, the skin being kept in good 
condition by daily vigorous rubbing with the band beneath the 
supporting bandage. In very young children the bandage must 
be changed when it becomes offensive. 

In this time (from six to eight months) it may be supposed 
that the accommodative contraction of the muscles about the joint 
and of the capsule will lessen the danger of redisplacement. 
The limb is then let down somewhat so that the patient is able 
to walk about without the aid of a high shoe. The second 



COXGEXITAL BISLOCATIOX OF HIP AND COXA VARA. 521 

bandage is retained for three months or more, and it is then re- 
moved, the period of retention being from eight to fourteen 
months, according to the stability of the joint at the time of 
reduction. In the treatment of very young children, when in 
testing the stability after reduction the femur is not displaced, 
even when the normal position is approached, the limb may be 



Fig. 30S. 




The after-treatment following the removal of the bandage in a case of bilateral 
dislocation, illustrating hyperextension of the thighs. 

In 450 operations reported by Lorenz, the following accicU 




Unilateral congenital dislocation, showing the fixation bandage. A shoe with a cork sole 
about two inches in height should be worn on the operated side, while the attitude of 
exaggerated abduction is maintained. 

fixed by the plaster in a Less di-torted attitude — what Lorenz 
calls the indifferent position of flexion, abduction, and outward 
rotation. 

9 . also, when the teste at the operation -li<>\\ fail- stability a 
second bandage Deed not be applied after a preliminary reten- 
tion of from h\ t<» nine months, bul it i- better to <tv on the Bide 
of safety in the matter of fixation. 



522 



ORTHOPEDIC SURGERY. 



When the retention bandage is finally removed the attitude of 
moderate abduction and outward rotation persists for a time, in 
some instances for several months. This being an indication of 
stability, is considered a favorable sign, and no attempt is made 
to correct it. In the after-treatment the limb is massaged, par- 
ticularly the posterior and lateral muscles of the hip, and the 
child is encouraged to abduct and to extend the thigh. Passive 
movements are made, also, in the direction of abduction and 
extension, the ability to reproduce the first or operation position 
during the early treatment being considered essential. In certain 
instances the child for a time should sleep in this position, the 
attitude being assured by a triangular cushion placed between the 
limbs and strapped to the thigh and pelvis. 




plaster bandage as applied by Lorenz, illustrating the extreme thickness of* 1 - , 

ui 6 ..wfcd i-jj— j. — *.■ — pf-f-n niT i r .^- ^ 6 iit angular 

flexion in bilateral dislocation. Compare with Fig. 311. 



Bilateral congenital dislocation is treated in exactly the same 
way as the unilateral. Both hips are operated upon at one 
sitting, and are fixed in the typical attitude (Fig. 304). Walking 
is, of course, difficult, but the child is usually able to stand, and 
after several months it is often able to get about on its feet after 
a fashion (Fig. 312). 

When the second bandage is applied the limbs are let down 
somewhat, but the degree depends, of course, on the initial 
stability. The after-treatment is the same as for the single 
dislocation, except, of course, that the subsequent period of 
awkwardness is much longer. Massage and exercises (Fig. 310) 
are far more important than in single dislocation, as the weakness 



COXGEXITAL DISLOCATION OF HIP AXD COXA VARA. 523 

is greater. The primary position during sleep may be assured 
by a cushion or roll placed between the thighs. 

Prognosis. The Lorenz operation is not without danger. The 
death-rate attributed to anaesthesia is disproportionately large in 
the cases reported, and in this the violence of the manipulations 
may be an important factor. 

Fig. 310. 




The after-treatment following the removal of the bandage in a case of bilateral 
dislocation, illustrating hyperextension of the thighs. 

In 450 operations reported by Lorenz, the following accidents 
occurred : 

Fracture of the neck of the femur in 11 cases. 

Fracture of the pelvis in 3 " 

Peroneal paralysis in 3 " 

Crural paralysis in 5 " 

Sciatic paralysis in 3 " 

In the last cases the paralysis persisted; in the others it was 
temporary. In 1 case the femoral artery was ruptured, the 
patient recovering without ill-effect. In 1 case gangrene of the 
extremity necessitated amputation at the hip-joint. 

It may be stated, however, that in the younger class of 
the operation, if conducted with reasonable regard to the resist- 
ance of the tissues and to the susceptibility of the patient, Is 
practically free from danger. 

In cases treated at the proper age — that is, under sis years 
bilateral and under eight for unilateral cases — nearly 50 percent. 



52 1 



ORTHOPEDIC SURGERY. 



of the unilateral and 25 per cent. (50 per cent, for each side) of 
the bilateral cases can be anatomically and functionally cured. 



Fig. 311. 




Illustrating the range of normal abduction of the thighs, from the attitude ot right 
angular flexion. 



Fig. 312. 




The bandage applied after the reduction of bilateral dislocation, showing 
a favorite method of progression on a chair. 



Nearly all the others can be greatly improved, in that the pos- 
terior displacement may be converted into an anterior one. In 



COXGEXITAL DISLOCATIOX OF HIP AXI) COXA VARA. 525 



Fig. 313. 



such cases, in which the head of the femur is forced forward 
below the anterior superior spine, the static conditions become 
approximately normal, and further displacement is to a great 
extent prevented by the firm tissues attached at this point. A 
stable articulation is assured by long retention of the limb in the 
position of abduction and extension by means of the plaster 
bandage and by exercises and 
passive movements after its 
removal. 

As has been stated, in success- 
ful cases the head of the femur 
can always be palpated directly 
beneath the femoral artery. The 
first indication of failure is a 
slight lateral displacement of the 
head to the outer side of the 
artery. This may appear even 
during the period of fixation, but 
often not until the plaster ban- 
dage is removed. At first there 
is no shortening, but slowly, as 
the displacement increases and as 
the head of the bone ascends 
from the neighborhood of the 
acetabulum to that beside or 
above the anterior inferior pelvic 
spine, this becomes evident. At 
first it is half an inch, later an 
inch, but it is not often more than 
this, at least during childhood. 

It has been stated that this 
outcome may be expected in about 
half of the favorable cases as to 
age in which all the details of 
the operation have been properly 
carried out, and it is the usual 
result iu the unfavorable class. 
This result, which is aot classed 
by Lorenz as a failure, but rather as an improvement, may be 
explained in certain instances l>v interposition of a fold of cap- 
sole between the head of the bone and the acetabulum, or by 
failure of the proa formation of the acetabulum. In most 




The cure of congenital dislocation. The 
same patient is shown in I- 'i. 



526 ORTHOPEDIC SURGER Y. 

cases, however, it is accounted for by an anterior twist of the 
upper extremity of the femur, so that the neck instead of point- 
ing inward and slightly forward from the shaft is turned forward 
and slightly inward. Thus, in order to replace the head in the 
acetabulum, the limb must be rotated inward until the foot points 
inward rather than forward. 

Occasionally the presence of this deformity may be ascertained 
before operation. It may be suspected, for example, in nearly all 
the anterior and supracotyloid displacements in older subjects, 
and it could be demonstrated, doubtless, by a series of Roentgen 
pictures. In most cases, however, the failure of treatment calls 
attention to the probable existence of the deformity. It is, of 
course, apparent that the only remedy is a cutting operation. 
Lorenz is content in these cases with anterior apposition, but if 
it is probable that a twist in the upper extremity of the femur is 
alone responsible for failure, it seems more reasonable to remove 
this by osteotomy. This operation will be described in connec- 
tion with the open operation. 

The Treatment of Older Subjects. It has been stated that 
the final result in a very large proportion of the operations was 
anterior transposition or apposition, as Lorenz calls it, and that 
in cases beyond the age of eight years this result is to be expected. 
In this class of cases — from ten to twenty-one years of age — it is 
the primary aim of the operation. After preliminary traction in 
bed and after subcutaneous division of the more resistant tendons 
if this is necessary, the limb is forced into moderate abduction 
and extreme extension, so that the head of the bone is displaced 
forward to the neighborhood of the anterior inferior spinous 
process. In this attitude the limb is retained for many months 
by means of the plaster bandage, and it is assured in the after- 
treatment by the manipulation and exercises already described. 
Although even in the most successful cases a limp persists, yet 
it is far less noticeable than in untreated cases, the discomfort is 
relieved, the limb is lengthened, and the danger of future disa- 
bility is much lessened. 

In those unusual cases in which the adduction and flexion 
deformity is extreme, osteotomy of the femur may be required, 
and if the pain is persistent excision of the hip may be necessary. 

The Treatment of Congenital Dislocation in Infancy. Occa- 
sionally one has an opportunity to treat congenital disloca- 
tion in early infancy. The details of treatment do not differ 
essentially from those already described, except, of course, that 



CONGENITAL DISLOCATION OF HIP AND COXA VARA. 527 

reduction is easily effected (Fig. 305) and that walking or weight- 
ing (functional use in other words) cannot be utilized at once in 
the after-treatment. In this class of cases, provided the test of 
the stability of the joint is satisfactory, one need not fix the 
limb in the extreme position. It is well, however, to carry the 
bandage below the knee in order to assure for a time more 
complete fixation. The support must be renewed whenever 
sanitary reasons indicate the necessity. In many instances cure 
is practically assured in a few months. 

Variations in the Treatment. It has been stated that the first 
indication of failure was ordinarily a slight lateral displacement 
of the head to the outer side of the femoral artery, and that this 
displacement was favored by the anteversion of the neck of the 
femur. As is well-known, anteversion of moderate degree is not 
unusual in the femora of apparently normal joints. In such 
instances subluxation is prevented by the cotyloid cartilage, and 
by the normal capsule which are wanting in the congenital dis- 
location. When, therefore, anteversion is suspected or is known 
to exist it is well to rotate the thigh inward, so that the head of 
the femur is slightly to the inner side of the artery, and to fix 
it in this attitude by extending the plaster bandage below the 
knee, the leg being slightly flexed upon the thigh. This attitude 
should be retained until it may be assumed that the capsule is 
sufficiently contracted to restrain the femur from reluxation. As 
has been stated, the writer considers the additional security 
attained by carrying the bandage below the knee of some impor- 
tance in treatment of infants and young children. 

Arthrotomy. If the Lorenz operation has failed when all the 
details have been thoroughly carried out, the advisability of an 
exploratory operation suggests itself. Under proper aseptic pre- 
cautions this should entail no danger, nor should it compromise 
the functional ability of the joint. One can then assure one's 
self that the head of the bone is actually replaced within the 
acetabulum. Arthrotomy is indicated also if the resistance to 
reposition by the ordinary method is so great that dangerous 
fon-e must be exerted to overcome it. 

The joint is exposed by a lateral incision about three inches in 
length, extending downward from a point about three-quarters 
of an inch to the outer side of the anterior superior spine of the 
ilium, the fascia is divided, and the line of junction between the 
tensor vaginae femoris and the gluten- medius muscles is found. 
These muscles are then separated and are drawn to either side by 



528 



ullTlluPEDIC SURGERY. 



retractors, thus exposing the capsule of the joint. This is 
opened by an incision parallel to the neck of the bone. The 
finger is then passed through the opening, clown upon the rudi- 
mentary acetabulum. A strong cervix dilator is next inserted 
and the contracted capsule is thoroughly stretched. If the 
ligamentum teres is present it is removed. 



Fig. 314. 



Fig. 315. 



* 




^1 





A successful result after the open operation, 
illustrating a useful form of brace to be used in 
the after-treatment to hold the limb in proper 
]K)sitiou,ifithas a tendency to rotate outward. 



Bilateral dislocation six months 
after replacement by the open meth- 
od in 1897, illustrating the change 
in the contour of the trunk. 



The head is then replaced ; the capsule and overlying tissues 
are united with catgut sutures. The limb is then fixed in the 
typical position by the Lorenz spica. In the majority of cases 
the cause of the failure of the primary operation is an antever- 
sion of the neck of the femur. In this event after replacement 
the limb must be rotated inward to the required degree and fixed 



CONGENITAL DISLOCATIOX OF HIP AND COXA VARA. 529 

by a plaster bandage extending below the knee as a preliminary 
to osteotomy. 

Osteotomy. 

When the limb has been fixed for several, preferably six, 
months, in the attitude of inward rotation so that stability is in 
some degree assured, the operation for correcting the anterior 
twi^t of the upper extremity of the femur should be performed. 

The plaster bandage having been removed, a long drill should 
be inserted through the trochanter and into the neck of the bone. 
This indicates the position of the neck and fixes the upper frag- 

Fig. 316. 




Scoops used in the treatment of congenital dislocation, also the subcutaneous osteotome 

A subcutaneous osteotome is then inserted a1 a point 

just below the trochanter minor or at the lower third of the 

femur, and a thorough division of the bone Is made. The lower 

tomy is perhaps to be preferred, because one baa better 

■ l of the fragments at this point. When the division is 

complete, tie- upper fragment being fixed by the drill, the limb 

outward until the normal relation between the Bhafl 

and tie- neck is restored. A plaster spies Including the foot 

is then applied, by which tin drill and the upper fragment are 



530 



ORTHOPEDIC SURGERY. 



fixed in proper relation to the shaft. Two weeks later, when 
the improved position is assured, this is withdrawn. The after- 
treatment is the same as in the uncomplicated cases. 



Fig. 317. 




Unsuccessful treatment by forcible correction (Lorenz operation). The posterior has 
been changed to an anterior displacement. Rear view. 



The Open Operation with Enlargement of the Acetabulum. The 
original Hoffa-Lorenz operation, once the treatment of routine, 



CONGENITAL DISLOCATION OF HIP AND COXA VARA. 531 

is now reserved for a restricted class of cases in which the blood- 
less operation has failed, and in which on opening the joint the 
acetabulum is found to be notably deficient. 

Supposing the shortening of the limb to have been overcome 
by previous treatment, the joint and capsule are opened in the 
manner already described. One finger is then inserted to the 
acetabulum aud by its side a strong, sharp, bayonet-shaped spoon 
(Fig. 316) is passed, and with it the shallow acetabulum is 
enlarged to a sufficient size, care being taken to accentuate its 
superior and posterior border. The head is then placed within 
it, and the wound is closed or packed according to the custom 
of the operator. A long plaster spica is then applied with the 
limb in an attitude of moderate abduction and extension. In a 
month, or when repair is complete, a short Lorenz spica is 
applied and the patient is encouraged to walk about. This 
support should be worn for from six months to a year in order 
to prevent the contractions that almost inevitably follow opera- 
fciona of this character. Exercise and forcible manipulation 
within a few weeks after the operation, as recommended by many 
writers, are not only of no service, but in the author's experience 
harmful. 

When the spica is removed and the patient is allowed to run 
about, motion usually returns. At this time massage should be 
employed and passive movements always in extension and abduc- 
tion. Later gymnastic training is of great value. After this 
operation, provided there is true anatomical cure, motion is 
usually restricted to a greater or less degree, and in older sub- 
jects there is often fibrous anchylosis. For this reason it should 
be limited to unilateral cases, or, at all events, one should never 
operate on the second hip until the result of the operation 
in the first is known. In unilateral cases anchylosis without 
deformity is not a serious functional disability, as there is solid 
support without shortening, while if fair motion is obtained, as in 
many instances, the functional result is far better than after simple 
transposition. It should be stated that even after the open 
operation tin- transposition is often the outcome. In such 
cases motion i~, of course, frc<', and tin- stability i- somewhat 
L r r»-:it<T than after tin; bloodless operation. If after this operation 
morion i- extremely limited, one must expect flexion and adduction 
deformity unless it Ik- prevented by careful treatment. In certain 
- the range of motion may !><• increased by breaking up 
adhesions and stretching the contracted parts under anaesthesia. 



532 



ORTHOPEDIC SURGERY. 



The danger of the operation is slight, and the deaths, with 
but few exceptions, have been due to infection. Lorenz and 
Hoffa lost several of their earlier patients from this cause, but 
with improved technique the danger is slight. 1 The bad results 
of the operation may, as a rule, be accounted for by its improper 



Fig. 318. 



Fig. 319. 





• 



& 




Unilateral dislocation. Two years 
after operation in 1897 by the Lorenz 
method. A complete cure. 



Unilateral dislocation. Eighteen months after 
operation by the Lorenz method in 1897. A com- 
plete cure. 



performance, particularly the failure to replace the femur securely, 
or by failure; to insure asepsis, or by inefficient supervision and 
after-treatment. 



1 Uoffa has performed the operation 248 times, with 10 deaths, 8 due to the operation, the 
operations without a death. Lorenz, in 260 operations, lost 4 patients from septi- 
cemia.— Report of the Thirteenth International Congress, Paris, August, 1900. 



It is perhaps unnecessary to state that operations of this char- 
acter should not be performed unless asepsis can be assured, 
unless the operator is familiar ^yith the anatomy of the parts, 
and unless the essential after-treatment can be provided. 

Review of the Treatment of Congenital Dislocation of the Hip. 
The prospect of success in treatment stands in direct relation 
to the age of the patient, since the extent of the pathological 



i 








I 




Unilateral dislocation, after operation 
by the Lorenz method com- 

plete cure. Compere with Fig. 238. 



Unilateral dislocv-." years after 

operation. Compare with F- 



cbanges that make cure difficult or impoasibli 
degree, as in acquired di~". -. upon the duration of th< 

ability. Consequently treatment should be applied as ^oon as 
the displacement is dh 1, there is 

little excuse for not making the correct di _ when the 

child begins to walk. The treatment of the fund 

g method of Lorenz. By tins means ;i larger prop 



534 ORTHOPEDIC SURGER Y. 

of the cases may be cured, and in all instances the posterior may- 
be changed into an anterior displacement, which is a great 
improvement. 

If one is not content with such partial success the treatment 
may be supplemented by arthrotomy, and if anteversion of the 
upper extremity of the femur prevents success it may be remedied 
by osteotomy. 

Excavation of the acetabulum will often assure anatomical 
success. 

Anatomical reposition with fair or even very limited motion 
assures better function in unilateral cases than transposition, but 
anchylosis with deformity is certainly no improvement on the 
original condition. It may be suggested, also, that the danger of 
open operation even if slight must be considered. 

In the treatment of adolescent cases one should attempt to 
obtain anterior transposition and to assure it by fixing the limb 
for a sufficient time in the improved position. 

As has been stated, the operation of bloodless reduction had 
been attempted and probably successfully performed long before 
the time of Lorenz. Its first advocate was Pravaz, of Lyons, in 
1847; and Paci, of Pisa, in 1887, described a method of reduction 
resembling in some respects that of Lorenz, but far less definite 
and effective, in that primary reduction was not assured nor was 
the weight of the body utilized in the after-treatment. 1 

Palliative Treatment. Palliative treatment does not require 
extended comment. In brief in unilateral cases a cork sole may 
be worn to equalize the length of the limbs, and in bilateral cases 
a corset suitably strengthened with steel supports may be adjusted 
if the lordosis is extreme. Exercise and passive manipulation 
with the aim of retaining, as far as possible, the ability to abduct 
and to extend the thighs may be of service in preventing 
secondary contractions. Overexertion that causes discomfort 
or pain should be avoided. 

Congenital Subluxation of the Hip. 

As has been stated, there are cases of congenital displacement 
of the hip which are in reality subluxations. In such cases there 
is a slight limp and slight shortening, and an X-ray picture 
shows a secure acetabulum somewhat above the plane of the 
opposite side. These subluxations are always of the anterior 

I Archiv. di Ortop., 1892. p. 420. 



CONGENITAL DISLOCATION OF HIP AND COXA VARA. 535 

variety. ]Xo treatment other than care to preserve the range of 
abduction is required as a rule. 

Snapping Hip. 

Some individuals possess the power of slightly displacing the 
hip, usually upon the superior or upper border of the acetabulum. 
This is sometimes seen in infancy, the child's thigh snapping with 
a jar or even audible sound upward and downward. This is 
usually accomplished when the child is seated in the mother's 
lap, the thigh being flexed and adducted, and in this class of 
cases it is, according to the mothers, an evidence of temper. As 
the displacement may be increased by habit, it is well to restrain 
it by applying a bandage about the hip and to prevent flexion of 
the limb, which is apparently preliminary to its accomplishment. 
(See Snapping Knee.) 

Coxa Vara. 

Synonyms. Depression or incurvation of the neck of the 
femur ; bending of the neck of the femur. 

The character of this deformity is indicated by the synonyms. 
The term coxa vara signifies that its causes and effects are 
similar to those of genu valgum and varum, the more common 
distortions of the lower extremities. 

Genu valgum and varum are common in childhood, but rarely 
develop in adolescence. Coxa vara is, in comparison, an infre- 
quent deformity, and it is peculiar in that it more often appears 
in later childhood or adolescence than at the earlier period, 
doubtless because the neck of the femur is, at the age when 
rhachitic distortions are common, very short, and, therefore, 
relatively stronger than the shaft, while in adolescence the con- 
dition- may be reversed. 

The distortions at the knee are self-evident, but the neck of 

the femur is concealed from view; thus the diagnosis of coxa 

vara may be somewhat difficult ; and, in fact, it is only in very 

its that it- symptoms have been recognized. Fiorani 1 

I the deformity as it had been observed by him in 

children, but E. Mailer 3 first called attention to the affection as 

one of the deformities of adolescence, which, until that time, had 

n for hi]» disease. 



- klin. Chir., 1889, Bd. iv. 



536 ORTHOPEDIC SURGER Y. 

Pathology. The term coxa vara should not be applied to 
depression of the Deck of the femur that may be secondary to 
destructive disease ; for example, to osteomyelitis, arthritis 
deformans, osteomalacia, and the like, but it should be reserved 
for eases of simple local deformity. In most instances the 
deformity affects the neck as a whole (cervical coxa vara) ; in 
others it is most marked at the epiphyseal junction (epiphyseal 
coxa vara). Epiphyseal coxa vara is more often found in the 
adolescent class, and particularly in those cases in which the 
symptoms have been induced or aggravated by injury or strain. 

Fig. 322. 




■fi§ 



Section of the upper extremity of a normal femur at eight years of age ; angle formed by 
the neck with the shaft 140 degrees. In the normal subject the neck of the femur projects 
slightly forward (12 degrees) and upward to form an angle with the shaft of about 125 
degrees. In childhood this angle is usually somewhat greater, and in later years it may be 
somewhat less than 125 degrees ; in fact, a variation between 110 and 140 degrees may be 
within the normal limit. 1 

Whether the injury caused primarily a partial epiphyseal separa- 
tion which afterward slowly increased under the strain of func- 
tional use or suddenly increased a pre-existing distortion of the 
weakened part is sometimes difficult to decide. A number of 
specimens of coxa vara have been examined, but no changes, 
other than such as might be caused by the deformity itself, have 
been found. These are, in brief, congestion and softening of the 
bone, and evidences of irritation within the joint during the pro- 
gressive stage of the deformity, and the general adaptive changes 

1 Humphrey. Journ. Anat. Phys., vol. xxiii. p. 236. 



CONGENITAL DISLOCATION OF HIP AXD COXA VAEA. 537 

in all the components of the joint that always accompany displace- 
ment or distortion. These may be considerable, including, in 
advanced cases, a change in the acetabulum, whose upper border 
is less sharply defined than normal. 

Etiology. Some writers assume that the weakness of the neck 
of the femur that predisposes to deformity is the result of local dis- 
ease, such as so-called local rickets or local osteomalacia. This is, 
however, simply a convenient hypothesis. Others believe the 
deformity to be symptomatic of late rickets, although evidence 
of general rhachitis is almost never present in the ordinary type 
as it appears in later childhood and adolescence. 

Coxa vara may be classed as one of the group of static deformi- 
ties of the lower extremity caused by a disproportion between the 
strength of the supporting structure and the burden that is put 
upon it. The support may be disproportionately weak, because 
of inherited delicacy of structure; it may be weakened by injury 
or by disease ; it may be overburdened by weight or strain. 

Mechanical Predisposition to Deformity. In many cases the pre- 
disposition to deformity is the result of a lessened angle of the 
femoral neck. This slight and predisposing depression, which 
appears to be, in many instances, the effect of early rhachitis, 
becomes exaggerated to deformity during later childhood or 
adolescence. Id this sense — that of a remote result — coxa vara 
might be classed as one of the rhachitic deformities. The impor- 
tance of this mechanical factor in the etiology was demonstrated 
to me by the investigation of a number of cases of simple frac- 
ture of the neck of the femur in childhood. In these cases the 
neck of the femur was, by the original injury, somewhat depressed, 
and although complete functional recovery followed, yet in a 
Dumber of the cases progressive deformity, attended by the 
symptoms of typical coxa vara, resulted. This could be explained 
only on the theory that the lessened angle, subjecting the part to 
greater -train, was the predisposing cause of the later disability. 
Other factors in the etiology may be general weakness, incident 
to rapid growth, direct injury, and the strain of occupation. 1 

In this connection it may be stated that fracture of the neck 
of the femur in childhood may cause a deformity which in the 
absence of a history could not be distinL r 'ii.-li<<l from the < 0^ linary 
form of coxa vara, of which, in fact, it is the traumatic form. 

aae of congenital coxa vara has been rej>orte<l by Kre<b:l CCentral. fttrCll 
k of the femur in congenital dislocation of the hip I 
mentioned in the section on that affection. 



538 



OR THOPEDIC S URGER Y. 



(See Fracture of the Neck of the Femur and Epiphyseal Sepa- 
ration.) 

Statistics. The deformity is far more often unilateral than 
bilateral, and more than three-fourths of the cases are in males. 
In a total of 109 cases collected from the literature, 83 were in 
males and 26 in females ; 85 were unilateral and 24 were 
bilateral. The more important details in the 54 cases that have 
come under my own observation are presented in the accompany- 
ing table. 

















Direction 


S3 co 


bib 

p 




No. 


Name. 


Date. 


Sex 


13 

2 

o 
33* 


Age. 


Dura- 
tion. 


of the dis- 
tortion 
forward 
or back- 
ward. 


•as 


a "3 

Is 


U QJ fcj CO 

O o ^2 

ssa% 

.52 ><*-& 

^ <U O Sh 


1 


Nelson 


Oct. 1896 


F. 


Right 


zy 2 


6 mos. 


Posterior 


i 


1 


Yes 


2 


Van Orden 


June, 1896 


M. 


" 


4 


1 year 


" 


No 


3 


Clayton 


April, 1891 


F. 


Left 


6 


4 mos. 


it 


" 


4 


Zeltermann 


Jan. 1898 


M. Right 


7 


6 mos. 


" 


% 


X A 


Yes 


5 


Vitt 


Mar. 1897 


<; 


Left 


7 


6 " 


" 


i 


1 


" 


6 


Brunjes 


Dec. 1901 


M. 


" 


7 


5 yrs. 


" 


i 


% 


Yes 


7 


Weneck 


May, 1902 


" 


" 


7 


2 " 


" 


g 


" 


8 


Tuit 


July, 1899 


F. 


" 


fy. 


6 mos. 


" 


% 


" 


9 


Seeger 


Mar. 1897 


" 


" 


8 


2 yrs. 


" 


i 


1 


No 


10 


Rose 


Jan. 1888 


" 


D. 


8 


3 " 


" 






" 


11 


Cohen 


June, 1898 


M. 


Right 


8 


6 mos. 


" 


1 


1^ 


Yes 


12 


Kebesky 


Aug. 1900 


" 


Left 


8 


6 " 


Downw'd 


/2 


" 


13 


Dengher 


July, 1900 " 


Right 


8 


1 year 


" 


/2 


A 


" 


14 


Hirsch 


Mar. 1897 


" 


Both 


9 


2 yrs. 


Anterior 






" 


15 


Sussman 


Aug. 1902 


F. 


Left 


10 


1 year 


Posterior 


U 


% 


" 


16 


Reardon 


Mar. 1898 


M. 


Both 


11 


6 " 


Anterior 






" 


17 


Beckmyer 


Mar. 1895 


" 


" 


11 


8 " 


Posterior 






" 


18 


Brill 


Mar. 1894 


" 


Right 


11 


lyear 


" 


i" 


i" 


No 


19 


Greer 


Jan. 1896 


" 


Left 


12 


8 yrs. 


«* 


l 


l 


Yes 


20 


Thomas 


Mar. 1898 


F. 


Both 


12 


1 year 


Anterior 


R-H 


Ya 


" 


21 


Buechler 


Nov. 1902 | M 


" 


12 


10 yrs. 


Downw'd 






Yes 


22 


Abrams 


Mar. 1898 F. 


Right 


13 


10 yrs. 


Posterior 


2 


Vi 
A 


No 


23 


Rutschmann 


July, 1896 | M. 


" 


13 


6 mos. 


" 


V* 


" 


24 


Fraad 


Nov. 1894 " 


" 


13 


1 year 


" 


V* 


% 


" 


25 


Shandley 


Dec. 1898 F. 


" 


13 


1 " 


" 


% 


IV* 




26 


Skidmore 


Nov. 1899 | M. 


Left 


13 


3 yrs. 


" 


1% 




27 


Cords 


May, 1900 " 


Right 


14 


3 mos. 


" 


Vi 


iy* 


Yes 


28 


Cunningham 


May, 1897 i F. 


Left 


14 


1 year 


" 




\v>. 


No 


29 


O'Neil 


Jan. 1902 " 


" 


14 


1 year 


" 


IX 


No 


30 


Herbert 


April, 1897 M. 


Right 


14 


6 mos. 


" 


1 


1 


" 


31 


Bruning 


Oct. 1897 " 


" 


15 


2 " 


" 


x 4 


1 


' ' 


32 


Betz 


June, 1892 1 " 


" 


15 


1 year 


" 


% 


3 




33 


Lawson 


Oct. 1897 " 


" 


15 


1 " 


" 


% 


\% 


" 


34 


Jensen 


Jan. 1902 F. 


Left 


15 


2 " 


" 


y* 


" 


35 


McHenry 


July, 1902 M. 


Right 


15 


8K" 


Posterior 


*i 




36 Rose 


Jan. 1896 " 


Left 


15 


14 mos. 


" 


% 


% 


" 


37 Allen 


April, 1897 


" 


" 


16 


1 mo. 


" 


i 


w* 


" 


38 Puckhaber 


June, 1893 


" 


Both 


16 


8 mos. 


" 






Yes 


■ J >'J Gieger 


May, 1900 


" 


Left 


16 


6 " 


" 


% 


ig 


No 


40 Schade 


Julv, 1898 


" 


" 


16 


18 " 


" 


i 


L 




41 Redfield 


May, 1901 


" 


Both 


16 


2 yrs. 


" 






" 


42 Laherty 


July, 1901 


" 


Left 


16 


7 mos. 


" 


1 


?3 


" 


43 Mortimer 


Nov. 1901 


F. 


" 


16 


12 yrs. 


Downw'd 


k 




14 McHenry 


Jan. 1902 


M. 


Both 


16 


2 " 


" 






No 


45 Morris 


Jan. 1900 


" 


Right 


17 


6 " 


Posterior 


H 


l 


No 


46 Jocker 


Dec. 1899 


" 


Left 


17 


1 mo. 


" 




" 


47 Beck 


July, 1898 


F. 


Right 


17 


1 year 


" 


i% 


" 


48 j Zimmermann 


Oct. 1896 


M. 


" 


17 


13 mos. 


" 


% 


*% 


" 


49 Healey 


Dec. 1900 


M. 


Left 


17 


8 " 


" 


X 


l 


" 


50 Fes^ner 


Mar. 1894 


" 


" 


17 


6 " 


" 


% 


% 


" 


51 1 Enderlich 


Jan. 1897 


F. 


Right 


22 


1 year 


" 


% 


l 


" 


52 Adult 


Mar. 1896 M. 


" 


36 




" 


1 


V/% 


" 


53 Hogan 


July, 1901 F. 


Right 


20 


7 yrs. 


" 


-% 


S 


" 


54 Hayem 


Oct. 1901 M. 


Both 


52 


30 " 














COXGEXITAL DISLOCATION OF HIP AXJD COXA VARA. 539 

The points of special interest in these and four other cases 
more recently observed may be summarized as follows : In about 
one-third of the cases there was a distinct history of rhachitis 
in infancy. The ages at which the symptoms became noticeable 
appeared to be as follows : 

Adolescents, twelve to seventeen 31 

Later childhood, five to eleven 17 

Early childhood, less than five 9 

Unknown , .... 1 

Total 58 

Forty-one of the patients were males, 17 were females. In 47 
cases the deformity was unilateral, 25 of the right and 22 of the 
left side ; in 11 it was bilateral. In 53 cases the neck of the 
femur was distorted in a direction backward and downward ; in 
3 directly downward ; in 4 forward and downward. In each 
case of the last group the deformity was bilateral. Many of the 
cases were observed before the X-ray was available for diagnosis, 
but it is estimated that in about one-fourth of the adolescent cases 
the distortion was greatest in the vicinity of the head of the bone 
(epiphyseal coxa vara) ; in the others the neck of the femur as a 
whole was involved. 

Symptoms, 1. Mechanical Effects, The character of the 
symptoms may be explained by a description of the distortion and 
of its direct effects upon the function of the joint. When the 
neck of the femur is depressed, for example, to a right angle with 
the shaft, the trochanter is elevated to a corresponding degree 
above Xelaton's line, and forms a noticeable projection as con- 
trasted with the normal contour (Fig. 326), a projection that 
becomes more marked wheu the thigh is flexed and adducted 
(Fig. 325). In most instances the neck is displaced backward 
as well as downward, following the line of least resistance, and 
as the head of the bone remains in the acetabulum the trochanter 
is thrown forward and the limb is rotated outward. The ability 
to abduct the thigh is dependent upon the length and upon the 
upward inclination of the femoral neck (Fig. 178) ; when, there- 
fore, this inclination is diminished the range of abduction is 
lessened, in part by the greater tension that is exerted upon the 
lower portion of the capsule, in part by the direct contact of the 
rim of the acetabulum with the neck and trochanter (Fig. 323), 
and in part by the adaptive contractions that always accompany 
displacements of this character. It is evident, also, that the dis- 
tortion of the neck backward and downward changes the relation 



540 



ORTHOPEDIC SURGERY. 



of the acetabulum to the head of the femur, so that abduction or 
flexion tends to displace it from its socket. Thus the range of 
abduction, of inward rotation, aud of flexion is limited, while 
that of adduction, outward rotation, and extension may be 
increased. 

There is actual shortening of the limb dependent upon the 
upward displacement of the shaft of the femur. This is not 
often more than an inch in the ordinary type of adolescent 
deformity, but the apparent shortening, caused by the adduction 
and the accommodative upward tilting of the pelvis, may be 
extreme ; from two to three inches is not uncommon (Fig. 326). 



Fig. 323. 




Skiagram of coxa vara ; deformity most marked at the epiphyseal junction. This illus- 
trates the mechanical limitation of abduction caused by the deformity, and the compensa- 
tory tilting of the pelvis. The patient is shown in Fig. 32*5. 



2. Physical Effects. The symptoms of coxa vara of the ordinary 
form are : discomfort, awkwardness, limp, shortening, atrophy, 
limitation of motion, deformity. 

Coxa vara is a more disabling deformity than genu varum or 
valgum, and its attendant symptoms of discomfort, weakness, 
and pain are, as a rule, more marked. This is explained by the 
fact that in coxa vara the head of the bone is in part displaced 
from the acetabulum (Fig. 324), while in the deformities at the 



COXGEXITAL DISLOCATION OF HIP AND COXA VARA. 541 

knee the joint surfaces remain in practically normal relation to 
one another. 

The symptoms of unilateral coxa vara vary with the degree 
and with the duration of the deformity. The patient usually 
complains of sensations of stiffness and weakness, referred to 
the thigh. These are more noticeable on changing from a position 
of rest to one of activity, and at times, particularly after over- 
exertion, there may be actual pain. By far the most important 
symptom and the one that almost always induces the patient to 
seek treatment is the limp. This limp, accompanied, as it usually 

Fig. 324. 




Cross-section of the pelvis and the deformed femur. A scheme to show the effect of the 
deformity in limiting abduction of the limb. The dotted outline shows the normal relation. 



La, by outward rotation of the foot, resembles that caused by 
united fracture of the neck of the femur. On physical exami- 
nation the actual shortening, explained by the elevated and 
prominent trochanter and the peculiar unequal limitation of 
motion, will make the diagnosis clear. In some instances there 
may be a slight degree of muscular spasm, and there is usually 
some atrophy of the muscles of the thigh. 

Bilateral Coxa Vara. If the deformity is bilateral its effect 
upon the L r air and attitude is more marked. The gait is 
extremely awkward, resembling somewhat that of knock-knees, 



5 12 ORTHOPEDIC SUROER Y. 

for the limitation of abduction forces the patient to sway the 
body from side to side in order that the legs may pass one 
another, and if the deformity is extreme the limbs may be crossed 
over one another, so that locomotion may be difficult. In the 
ordinary form of bilateral coxa vara the femoral neck on each 
side is displaced backward as well as downward, and as the 
head of the femur remains in the acetabulum the shaft is thrown 
forward, so that the trochanter is nearer the anterior superior 
spine than is normal. This displacement of the support lessens 
the inclination of the pelvis and lessens the normal lumbar 
lordosis. Bilateral coxa vara is not infrequently accompanied 
by other deformities, as, for example, knock-knee or flat-foot 
(Fig. 327). 

Other Varieties of Coxa Vara. In rare instances the neck of 
the femur may be depressed directly downward or even down- 
ward and forward. In the latter instance the effect of the 
deformity upon the function of the joint is somewhat different 
from that of the ordinary type. Abduction is limited as in the 
common form, but inward rotation replaces outward rotation, 
and extension is limited in place of flexion. This type of 
deformity is almost always bilateral. It is accompanied, usually, 
by slight permanent flexion of the thighs ; thus the lumbar 
lordosis is exaggerated ; whereas, in the ordinary form it is 
usually lessened. 

This description applies to the ordinary types of the deformity 
as it is seen in later childhood and in adolescence. It undoubt- 
edly occurs in early life, but it is masked by the more noticeable 
distortions of other parts, and as an isolated deformity that 
demands treatment it is uncommon. One case was observed by 
the writer in a rhachitic child two and one-half years of age. 
The symptoms, though slight, were typical, and the diagnosis 
was confirmed by a Roentgen picture. In other cases seen in 
later childhood, the history of more or less discomfort for many 
years seemed to indicate that the deformity was caused directly 
by rhachitis. 

In the majority of cases the symptoms begin insidiously, 
although, in many instances, they may follow injury or over- 
exertion. (See Partial Epiphyseal Separation.) If the affection 
begins in adolescence and is untreated, the period of discomfort, 
during which the depression of the neck may be assumed to be 
progressive, is from two to four years ; but if the deformity 
appears at an early age, the symptoms, though remittent in char- 



COXGEXITAL DISLOCATIOX OF HIP AXD COXA VARA. 543 

acter, may continue indefinitely. "When the resistance of the 
compressed bone becomes sufficient to insure stability, the dis- 
comfort ceases and the disability becomes less marked, as nature 
accommodates the mechanism to the new conditions. 



Fig. 325. 



Fig. 326. 





Coxa vara, showing the prominent trochanter. 



niustrating the tilting of 
the pelvis and the apparent 
shortening of the limb in 
unilateral coxa vara. Actual 
shortening, three-fourths of 
an inch ; apparent shortening, 
two and a half inches. The 
deformity of the epiphyseal 
type was apparently induced 
by overexertion. (See skia- 
gram, Fig. 323.) 



Diagnosis. In most instances diagnosis may be easily made, 
and yet coxa vara is very often mistaken for hip disease; in fact, 
we are indebted to this mi-take for most of the specimens of the 
deformity that have been described. The essential differences 
between th<- two are as follows : In tuberculous disease of the 



544 



ORTHOPEDIC SURGERY. 



hij) the motions of the joint are limited in every direction by 
re Hex muscular spasm, and, as a rule, other evidences of the 
character of the disease are apparent. Coxa vara is a simple 
deformity ; reflex muscular spasm is absent, except during 
exacerbations due to injury or overstrain, and movement is not 
limited in all directions, but only in abduction, flexion, and 
inward rotation when the deformity is of the ordinary type. 
Actual shortening is a late symptom of hip disease, while it is 
present from the very onset of coxa vara. It is a shortening 
explained by the elevation of the trochanter above Kelaton's line, 



Fig. 327. 




Double coxa vara of advanced degree, showing the involuntary crossing of the 
legs in flexion. 

while such elevation in hip disease is a sign of destruction, either 
of the head of the bone or of a part of the acetabulum. 

The deformity might be readily mistaken for congenital dislo- 
cut'ion of the hip, particularly of the anterior variety, but this 
would be excluded by the history, since coxa vara is an acquired 
deformity. The diagnosis between the two affections may be 
easily made on the physical signs alone. In congenital disloca- 
tion, if the thigh be flexed and adducted to its extreme limit, the 
head and neck of the displaced bone can be distinguished beneath 
the distended tissues of the buttock. In coxa vara nothing but 
the prominent trochanter can be made out on similar manipula- 



COXGEXITAL DISLOCATION OF HIP AND COXA VARA. 545 

tion, while the abnormal mobility, characteristic of the dislocation, 
is absent. There is, however, a form of anterior dislocation in 
which the head of the femur has a secure support beneath the 
anterior superior spine in which diagnosis from the physical signs 
alone may be somewhat more difficult. An X-ray picture will 
always make the distinction clear, however. 



Fig. 32S. 



Fig. 329. 





Unilateral coxa vara, showing the effect of slight 
depression of the neck of the left femur upon the 
attitude. (See Fig. 329.) 

Treatment. If the deformity 

discovered in the early stage, 

illicit hope to check its progress 

by a change in the surroundings and 

occupation of the patient Standing, _ ., 

1 & ' The patient, Fig. 828, eight months 

particularly in the attitude of rest, alter cuneiform osteotom 

, • , 1 r • , . I late cure, both as rewards lymptomi 

Which throws additional Weight upon and deformity. 

eakened part, should be avoided, 

and work of any kind that induces the familiar symptOD 
strain should be discontinued. As much time as possible should 



54G ORTHOPEDIC S URGER Y. 

be spent in the open air, and diet and proper therapeutical remedies 
should be employed if evidence of constitutional weakness or 
rhachitis is present. 

Locally massage of the limbs and joints and forcible manipula- 
tion, with the aim of overcoming as much of the restriction of the 
range of abduction as may depend upon the secondary changes 
in the soft parts, should be employed, reinforced by regular 
gymnastic exercises, with the object of improving the circulation, 
upon which the repair of the weakened bone depends. 

If the deformity is unilateral temporary support may be em- 
ployed. A perineal crutch (Fig. 226) or, if the circumstances 
of the patient permit, one of the convalescent hip splints that 
allows motion at the knee, may be used (Fig. 231). With sup- 
port during the time of greatest strain — that is, when continuous 
walking or standing may be acquired — combined with proper 
exercises and massage, the weak part may become sufficiently 
strong to perform its function in a year or more, but supervision 
will be necessary for a much longer time. 

Operative Treatment. Forcible Abduction. In certain instances, 
particularly those cases in adolescence in which the symptoms 
have advanced rapidly, it may be inferred that the bony structure 
of the affected neck is congested and softened. One may attempt, 
therefore, to restore the angle by forcibly abducting the thigh, as 
in the treatment of fracture or epiphyseal separation. (See page 
549.) In this manoeuvre the head is fixed by the lower portion 
of the capsule, and the deformed neck is forced against the upper 
border of the acetabulum as illustrated in the figures (Fig. 331). 
If the normal range of abduction can be restored, one may infer 
that the deformity has been corrected. The limb should then be 
fixed by a plaster spica bandage in this attitude of extreme abduc- 
tion for two months, or until a time when consolidation in the new 
position is apparently complete. 

A support should be used for a time, and the usual treatment 
by massage and exercise should be carried out during the period 
of convalescence. 

Linear Osteotomy. The simplest and most efficient means of 
overcoming the adduction in older subjects is linear osteotomy of 
the shaft of the femur just below the trochanter minor. This 
may be performed by the subcutaneous method, as in the correc- 
tion of the deformity of hip disease. When the bone has been 
divided the shaft is rotated inward until the foot is brought to 
the normal attitude, and it is then abducted to the normal limit ; 



CONGENITAL DISLOCATION OF HIP AXD COXA VARA. 547 

in this attitude a plaster spica bandage is applied reaching from 
the axilla to the toes. 

If the deformity is bilateral it is often sufficient to operate on 
the limb which is most affected. "When the fracture is consolidated, 
massage, exercises, and manipulation are employed, as has been 
described. It may be assumed that the increased blood supply 
necessitated by the repair of the injury will affect favorably the 
weakened bone as well. The final result in several cases, in which 
the operation was performed by the writer, was very satisfactory. 

Cuneiform Osteotomy. In younger patients the deformity may 
be remedied by removal of a cuneiform section of bone from the 
upper extremity of the shaft at the level of the trochanter minor 
(Fig. 330). In childhood the neck of the femur is short and 
the strain to which it is likely to be subjected slight ; thus opera- 
tive treatment may be indicated as a prophylactic measure. In 
fact, one should treat this deformity at the hip on the same 
principles as the similar distortions at the knee. Coxa vara can- 
not be rectified by mechanical treatment ; therefore, unless it is 
directly contraindicated operative intervention should be advised. 

In the technique of this procedure there are several points of 
importance. First, the restriction of abduction, of ligamentous 
or muscular origin, must be overcome by vigorous stretching and 
massage of the shortened tissues before the operation on the bone, 
otherwise it will be difficult to bring the two fragments into 
proper apposition. An incision is made from a point about one 
iuch below the apex of the trochanter directly downward about 
three inches in length. The bone is thoroughly exposed by 
separating the periosteum from the site of operation. The base 
of the wedge should be about three-quarters of an inch in breadth, 
directly opposite the trochanter minor ; the upper section should 
be practically at a right angle with the shaft, the lower beiug 
more oblique (Fig. 330, 2). The cortical substance on the inner 
aspect of the bone should not be divided, but, reinforced by the 
cartilaginous trochanter minor, should serve as a hinge on which 
tic ahaft <»f the femur is gently forced outward, until the opening 
Lb closed by the apposition of the fragments after the upper seg- 
ment has been fixed by contact with the margin of the acetabulum 

I _ : thus the continuity of the bone is preserved. The 

limb ifl then fixed in the attitude of extreme abduction by means 

of a plaster spica bandage, which should include the foot also, for 

about eight weeks, or until the union i- firm. When the limb is 

_ r ht to the line of tic body the neck of the femur is restored 



548 



ORTHOPEDIC SURGERY. 






to its proper position (Fig. 330, 4)- This mechanical method of 
apposing the fragments is far more effective than any system of 
suture, and if the operation is carefully conducted there is no 
danger of displacement. In ordinary cases of this class, accord- 
ing to the writer's experience, the cure is absolute, both as to 
symptoms and to function. No after-treatment other than the 
support of a short Lorenz spica for a month or more is required. 
The opportunity for treatment of coxa vara in earliest childhood 
is rarely offered. It is usually the direct result of rhachitis, and 



Fig. 330. 





1. The normal femur. 2. Depression of the neck of the femur— coxa vara. A. A wedge of 
bone has been removed. 3. Abduction of the limb first fixes the upper segment by contact 
with the rim of the acetabulum, then closes the opening in the bone. 4. Replacement of the 
limb after union is completed elevates the neck to its former position. 

in the early stage at least it is probably accompanied by other 
rhachitic distortions. It would be well, therefore, to examine 
the hip-joints of rhachitic children, especially those who present 
the deformity of genu valgum with reference to this distortion. 1 

Fracture of the Neck of the Femur. 

Traumatic Coxa Vara. Fracture of the neck of the femur 
in childhood, although until recently unrecognized, is by no means 



1 The bibliography of the subject, to the extent of 127 references, may be found in an article 
by Wagner in the Zeits. f. Orth. Chir., 1900, B. viii. H. 2. 



COXGEXITAL DISLOCATIOX OF HIP AXD COXA VARA. 549 

an uncommon accident, since twenty cases have come under the 
writer's observation during the past nine years. 

Fracture of the neck of the femur in childhood, however, 
differs markedly in its symptoms and in its effects from that in 
later life. In childhood the immediate effects of the injury are 
far less disabling, and the patient is often able to walk about 
within a few days after the accident, from which it may be in- 
ferred that there is, in many instances, a bending and breaking 
of the neck without actual separation of the fragments. During 

Fig. 331. 




1. Fracture of the neck of the femur. 2. Restoration of the normal angle by forcible 
abduction. 3. The limb in normal position. Figs. 4, 5, and 6 illustrate separation of the 
■ be head of the femur treated by the same method. 



teriod of repair the limp and attendant discomfort are usually 

mistaken for symptoms of hip disease. 

sis is usually simple. In all the cases there is a 
J of injury, usually a fall from a height, which confined the 
;♦ to the bed for several day- or weeks. On physical exam- 
d shortening of half an inch to an inch la found, explained 

by the corresponding elevation of the trochanter. .Motion in the 

joint i- more or less restrained by voluntary and involuntary con- 
i the muscles, bui this restriction La much more marked 

in flexion, abduction, and inward rotation than in other direc- 






550 ORTHOPEDIC SURGER Y. 

tioDs ; a limitation explained by the nature of the displacement, 
the neck of the bone having been forced downward and backward. 

The immediate effect of the injury is, as has been stated, less 
marked than in the adult, but the deformity often tends to 
increase in later years, because the right-angled relation of the 
neck to the shaft exposes it to greater strain. In a number of 
the patients examined several years after the injury, there was 
an increase of the actual shortening combined with permanent 
adduction. At this time the deformity could not have been dis- 
tinguished, except for the history, from the ordinary coxa vara 
of a rather extreme degree. 

Treatment. If the diagnosis is made after the accident, or 
before consolidation is complete, one should attempt to replace 
the neck in its proper relation with the shaft in order that subse- 
quent deformity may be prevented. This may be accomplished 
by forcing the limb into extreme abduction, and in this position 
a plaster bandage, reaching from the axilla to the toes, should 
be applied (Fig. 331). 

After consolidation of the fracture a hip splint or Lorenz spica 
may be worn for several months or until complete repair has 
taken place. Massage and forcible manipulation, if limitation of 
motion remains, combined with the avoidance of overstrain, may 
prevent the increase of the deformity. Otherwise the neck of 
the femur should be replaced in its normal position by the 
removal of a sufficient wedge of bone from the base of the 
trochanter as described under the treatment of simple coxa vara 
(Fig. 330). 

Traumatic Separation of the Epiphysis of the Head of the Femur. 
As has been stated, in traumatic depression of the neck of the 
femur the fracture is usually at about the centre of the neck, 
which in childhood is but little more than an inch in length. 
In exceptional cases the head of the femur may be separated at 
the epiphyseal line. This disjunction is more likely to occur in 
adolescence and particularly in subjects suffering from coxa vara 
in the early stage. Thus sudden disability, following slight 
injury, in an adolescent who has complained of discomfort and 
limp for some time before, and who presents on examination the 
signs of depression of the neck of the femur, would suggest this 
accident ; but the exact diagnosis can be established only by a 
Roentgen picture or by operation. 1 

1 Sprengel. Archiv f. klin. Chir., 1898, B. xlvii., S. 805. Clarke, Lancet, October 27, 1900. 



CONGENITAL DISLOCATION OF HIP AND COXA VARA. 551 

The treatment is similar to that of fracture, but the functional 
derangement of the joint is likely to be greater for the reason that 
the articulating surface of the head of the femur is involved. 1 

Partial Epiphyseal Separation in Adolescence. As has been sug- 
gested, slight injury may, under favoring conditions, rupture the 
periosteum and the cortical substance at the junction of the 
epiphysis and the neck of the femur, and under the influence of 
use the head of the bone may be slowly depressed, the final result 
being the epiphyseal type of coxa vara that has been mentioned. 
The symptoms of this variety of deformity, which is practically 
limited to adolescence, resemble those of the ordinary form, 
except that they are more marked and more disabling. 

In other cases the displacement may be greater or practically 
complete, in which case the disability is immediate, although the 
traumatism was apparently very slight. 

This accident under these conditions practically never occurs 
in healthy children. Particular attention is called to this point, 
as the two classes of cases are usually confounded, traumatic 
depression of the neck of the femur being classed, as a rule, as 
epiphyseal separation. 2 The treatment has been described in the 
preceding section. 

Fracture of the Neck of the Femur in Adult Life. The treatment 
by forcible abduction and fixation recommended for incomplete 
fracture of the neck of the femur or epiphyseal separation in 
childhood applies also to the same injury in older subjects. If 
the separation is complete the patient, under anaesthesia, is placed 
upon a pelvic support. Counter-traction is provided by a wide 
bandage passed between the thighs about the pelvis and fastened 
to the head of the table. The assistant makes traction on the 
liinlis, gradually abducting them. When the limit is reached on 
the sound side the limb is retained in this position to serve as a 
model for the other and to aid in fixing the pelvis. A long 
plaster spica is then applied in this attitude of extreme abduction 
nil extension over the knitted drawer, as described elsewhere. 
In certain instances, particularly in older subjects, the short 
Lorenz spica may be applied instead. 

( )ih- often encounters cases in which the disability persists after 
fracture of the neck of the femur — a disability due in great part 
to flexion and adduction deformity. Such deformity may be, in 

:.ian. Medical Record, July 25, 1893; Annals of Surgery, June, 1897. February, 
18 r >9, and November 

i. Zeit-chrift f. Orthop. Chir., 1903, Band xi. Heft 3. 



552 ORTHOPEDIC SURGERY. 

many instances, reduced by moderate force. If, as is often the 
case, the fracture has failed to unite, the upper extremity of the 
femur may be forced forward beneath the anterior superior spine 
and the limb may be fixed in an attitude of abduction and 
extension by a Lorenz spica, as originally suggested by Lorenz. 

Coxa Valga. 

Coxa valga is a term used to signify an abnormal elevation of 
the neck of the femur in its relation to the shaft, in contrast to 
coxa vara, an abnormal depression. This deformity is sometimes 
observed in limbs which have never supported weight. It is a 
possible result of injury also. It is of no importance from the 
orthopedic standpoint. 



CHAPTEE XVI. 

DEFORMITIES OF THE BOXES OF THE LOWER EXTREMITY. 

Of the distortions of the lower extremity bow-leg and knock- 
knee are by far the most common, comprising about 15 per cent, 
of the total cases in orthopedic clinics. Of the two bow-leg is 
the more frequent in all tables of statistics, and it is probable 
that the proportion of bow-leg to knock-knee is much larger than 
would appear from the hospital records ; for genu valgum is 
generally recognized as a serious deformity, while bow-leg is 
known to be of little consequence except from the aesthetic stand- 
point, so that its rectification is more often trusted to the power 
of nature. 

Both deformities appear to be more common in male than in 
female children — a fact explained, perhaps, by the greater weight 
and the greater susceptibility of the former. But here, again, 
statistics may be influenced somewhat by the fact that bow-legs 
are considered to be of more consequence to the boy than to the 
girl, because of the concealment that the skirts will insure if the 
distortion is not outgrown in childhood. 

Statistics. The relative frequency of the two deformities 

may be indicated by the statistics of the Hospital for Euptured 

and Crippled for a period of ten years. During this time 5441 cases 

were recorded, 3452 cases of bow-legs (63.4 per cent.), 11)8!) of 

knock-knees (37.6 per cent.). Of the 3452 cases of bow-legs 

were in males (58.8 per cent.), and 1422 were in females 

1 - . - per cent.). The 1989 cases of knock-knees were more 

divided between the sexes, 1024 being in males (51.4 per 

. and 965 in females (48.6 percent.). 

It will be noted that 45 of the cases of genu valgum were 
in patients over fourteen year- of age, as compared with •'» 1 
.f adolescent or adult bow-legs. The writer's personal expe- 
rience in the clinic enables him to state that a large proportion 
of th( mi valgum actually developed or increased to 

an extent demanding treatment during adolescence, while mosl 
of th< & bow-leg deformity in patients more than fourteen 



564 ORTHOPEDIC SURGERY. 

years of age luul existed since early childhood or were the result 
of injury or disease. 

Bow-legs. 

Year. No. cases. Males. Females. Over 21. Over 14. 

1 1899 400 236 164 5 

2 1898 406 255 151 2 

3 1897 467 268 199 4 1 

4 1896 356 200 156 1 

5 1895 336 200 136 2 1 

6 1894 310 170 140 1 2 

7 1893 262 157 105 3 3 

8 1892 306 189 117 1 2 

9 1891 303 174 129 1 1 

10 1890 306 181 125 1 3 



Year. 

1 1899 

2 1898 

3 1897 

4 1896 

5 1895 

6 1894 

7 1893 

8 1892 

9 1891 

10 1890 

1989 1024 965 16 31 

The Etiology of Genu Valgum, Genu Varum, and of Other 
Distortions of the Bones of the Lower Extremity. The 
common predisposing cause of simple deformities and disabilities 
of the lower extremities — in other words, those not caused by 
local injury or local disease — is the erect posture, when for any 
reason the bones and the joints are unequal to the strain of 
locomotion and to the task of sustaining the weight of the body. 

Time of Onset. At two periods of life the deformities under 
consideration most often develop. The first is in early childhood, 
when the upright posture is first assumed ; the second is in 
adolescence, when the rapid growth and other changes incident 
to this period may lessen the stability of the supporting structures, 
and when the strain of laborious occupation may be added to 
that of the increasing weight of the body. 

The deformities of adolescence are, however, relatively insig- 
nificant in number compared with those of early childhood, for in 
childhood inherited weakness or weakness that is the direct 
result of malnutrition at once develops into deformity under the 
-train of standing and walking. Thus, as a rule, the deformities 
under consideration first attract attention soon after the child 



3452 


2030 


1422 


13 


21 


Knock-knees. 








No. cases. 


Males 


Females. 


Over 21. 


Ovei 


202 


120 


82 


1 


4 


233 


135 


98 





11 


222 


120 


102 


2 


5 


232 


101 


131 








210 


109 


101 





2 


212 


86 


126 








162 


80 


82 


1 


2 


168 


89 


79 


8 


2 


189 


92 


97 


1 


2 


159 


92 


67 


3 


3 



DEFORMITIES OF BOXES OF LOWER EXTREMITY. 555 

begins to walk, and the patients are usually brought for treatment 
during the second or third vear of life. If the deformities " r are 
severe the body usually presents the evidences of general rha- 
chitis ; in other instances the distortion of the legs is almost 
the onlv sign of its presence, and in a certain number there may 
be no evidence whatever of malnutrition or disease. 

Predisposition to Deformity. It is not always easy to explain 
why weak legs bend in one way rather than in another. In 

Fig. 332. 




Habitual posture as a factor in the etiology of rhachitic bow-leg. 

some instances it is probable that a slight degree of deformity is 
present before the child begins to walk. For example, a slight 
outward bowing of the legs is said to be common in early infancy, 
and the use of heavy diapers might favor an increase of the dis- 
tortion. Knock-knee may be induced, apparently, by folding 
ifant on the arm with the knees pressed against the chest, 
and certain cases of knock-knee and bow-leg combined appear 
to be caused directly by tin- manner <>f carrying the infant 
habitually upon one arm. 



556 ORTHOPEDIC SURGER Y. 

The legs of rhachitic children, who have never walked, are 
often somewhat distorted, and in many instances this may be 
explained by the habitual postures (Fig. 332). 

A moderate degree of bow-leg is not infrequently seen in 
vigorous infants who stand and walk at an early age. Aside 
from the determining curve in the bone that may be present 
before the child begins to walk, this predisposition toward bow- 
leg may be explained, perhaps, by the fact that young infants 
often separate the feet widely in walking, and the swaying of 
the body from side to side may tend to bend the legs outward. 
In weaker or less vigorous children a slight degree of knock- 
knee is not uncommon, induced more directly by weakness or 
inactivity of the muscles, as a result of which the child stands 
with the knees somewhat flexed and pressed together, while the 
feet are separated and everted, an exaggeration of the so-called 
attitude of rest. 

Bow-leg is not uncommon in adult life, and it is popularly 
associated with strength and activity. Undoubtedly the attitudes 
of activity would tend to induce bow-leg rather than knock- 
knee, so that this tradition may have a foundation of truth. It 
is said to be common among those who ride constantly, and it 
may be a direct result of injury or disease of the knee-joint, but 
it may be stated that well-marked bow-leg in an adult has almost 
always existed since childhood. This statement cannot be made 
of genu valgum, since it may develop or increase during ado- 
lescence or even in adult life. The predisposing cause is weak- 
ness or overstrain, and, as has been stated, in the popular mind 
the deformity is characteristic of weakness. 

The Attitude of Rest. Genu valgum is an exaggeration of 
what is known as the attitude of rest or relaxation, in which the 
weight of the body is thrown in great part upon the ligaments of 
the three joints of the lower extremity. In the attitude of rest 
the pelvis is tilted forward, the femora are rotated inward upon 
the tibise, and the feet are separated and everted, so that the 
greatest strain falls upon the inner side of the knees and of the 
feet. Thus, what is known as flat-foot is often combined with 
knock-knee ; knock-knee may cause flat-foot, but more often the 
Hat-foot may induce knock-knee, or both may be the effect of the 
same general cause. Genu valgum, in the slighter degree at 
least, may be induced directly by improper attitudes, but the 
attitudes are, as a rule, the result of overwork to which the 
mechanism is subjected ; thus the knock-knee of adolescence is 



DEFORMITIES OF BOXES OF LOWER EXTREMITY. 557 



■& 



there synonymous with genu valgum. 

Genu valgum may be secondary to distortion elsewhere. For 
example, compensatory knock-knee is usually combined with 
extreme adduction of the thigh ; it may be the result of the 
inactivity necessitated by the treatment of hip disease ; it may 
be a direct result of injury, and it is sometimes an accompaniment 
of osteomyelitis or osteoperiostitis of the tibia, which causes an 
overgrowth and abnormal lengthening of the leg. There are, 
however, exceptional cases which would not be classed with the 
ordinary deformity. 

The Outgrowth of Deformity. In considering the treatment of 
the simple static deformities of the lower extremity which are 
usually the result of a temporary weakness of structure, one must 
first answer the question, "Will not the child outgrow it?" 
This belief in the spontaneous cure of deformity is very strong, 
not only among the laity, but among physicians as well ; and it 
rests upon the common observation that crooked legs become 
straight, or at least less deformed, with the growth of the child. 
In fact, if one were to judge from the general observation of the 
effect of growth upon the deformities of this class, or even from 
the tracings of the legs of rhachitic children taken from year to 
year, one might conclude that all deformities of this class might 
be safely left to themselves. As an illustration of positive evi- 
dence on the subject, the observations of Kamps 1 on 32 cases of 
rhachitic distortion of the lower extremity may be cited. Four 
and one-half years after the cases were first seen and recorded 
examination showed that 75 per cent, were cured, 15.3 per cent, 
improved, while 9.7 per cent, were unimproved. His conclu- 
sions are that such deformities do not, as a rule, require special 
treatment in early childhood, but that after the age of six years 
the prognosis for spontaneous cure is unfavorable. 

Wit 2 photographed a number of rhachitic children seen in the 
surgical clinic of the University of Berlin, and after a lapse of 
two or three years made another series of photographs of the 
same patients, who had meanwhile received no treatment. His 

iclusions are similar to those of Kamps, namely, that surgical 
treatment is not required for deformity of this character in chil- 
dren less than six years of age. In two classes of cases, however, 
the prognosis for spontaneous cure is not favorable, those in 

zur kiln. Chlr., B. xiv. EL I. 
hivf. kiln Chlr., B. L, S. 180. 



:,:»s 



ORTHOPEDIC SURGERY. 



which the growth has been checked by the rhachitic process, and 
in certain cases of extreme bow-legs, " O " legs (Fig. 333). 

The rectifying force of nature acts in two ways. Assuming 
that the deformity reached its limit during the period of original 
weakness, it must, of course, become relatively less as the body 
increases in length and size. In fact, the outgrowth of deformity 
has a direct relation to the rapidity of growth during the early 
years of childhood. The second manifestation of the power of 
nature is more positive. It may be assumed that when the 

deformity is progressive all the 
tissues are affected by the weak- 
ness ; consequently the attitudes 
of the child are those that can 
be most easily assumed under 
the abnormal conditions. But 
when the primary cause of the 
weakness, in most instances 
rhachitis, is no longer opera- 
tive, the muscles take on new 
activity and vigor, and the ac- 
tions and attitudes, in spite of 
the deformity, become approxi- 
mately normal. Then, accord- 
ing to Wolff's law of transfor- 
mation, the internal structure 
of the affected bones begins to 
change to accommodate itself to 
the new conditions of weight 
and strain induced by the 
change in action and attitude ; 
and to this rearrangement of the internal structure the external 
shape of the bones must conform in a gradual growth toward the 
normal contour. 

On this theory it is easily explained how the natural outdoor 
life of the country has long been celebrated as an effective treat- 
ment for this class of deformity. But it by no means follows 
that deformity is always outgrown even under favorable condi- 
tions. Improper attitudes that favor and cause deformity are 
often observed among those who are free from weakness and 
disability and from the influences of unfavorable surroundings ; 
and such attitudes are, of course, more likely to persist in those 
who were once obliged to assume them because of weakness and 




A type of deformity in which the prognosis 
as regards outgrowth is bad. 



DEFORMITIES OF BOXES OF LOWER EXTREMITY. 559 

deformity. Again, the weakness of structure or function may 
be an inherited peculiarity, or it may be induced by disease or 
by improper surroundings, influences that may continue for many 
years and thus serve to check the natural tendency toward cure. 
The observations on the outgrowth of deformity have been 
confined, as a rule, to the period of childhood, and most often 



Fig. 334. 




Extreme deformities, the result of infantile rhachitis. The left leg forms practically 
a right angle with the thigh. (See Fig. 338.) 



they have been made with reference to the more serious grades 
of distortion, which are the direct result of rhachitis. 

It must be borne in mind, however, that the true significance 
of these deformities in the adult must be judged from the 
aesthetic rather than from the medical point of view, and 
although the extreme degrees of bow-leg and knock-knee are 
relatively rare, yet in the minor grade both deformities are very 



560 ORTHOPEDIC SURGERY. 

common in adult males and in all probability in adult females 
also. 

In 1887 the writer 1 noted, among 2000 adult males observed 
on the streets of Boston, 400 cases of bow-leg and 32 cases of 
knock-knee. One may assume, then, that the legs of about one 
adult male in five deviate more or less from the line of sym- 
metry — a conclusion that has been confirmed by many subsequent 
observations. It may be admitted that a certain number of the 
distortions under consideration are acquired during adolescence, 
but it is probable that the greater number of those that may be 
noted in walkers upon the streets represent the incomplete out- 
growth of a deformity of childhood. 

The statement is often made that these distortions of the legs 
are common in childhood, but rare in adult life. Just what the 
proportion may be in childhood it is impossible to say, but it is 
not likely to be greater than one in five. One must conclude 
that statistics, on which such statements are based, have been 
made up from the records of hospitals where it is extremely 
uncommon for an adult to apply for the treatment of bow-leg, to 
which he has become accustomed since childhood, unless the 
deformity is extreme or is attended by pain. 

Granting that the power of nature is quite sufficient to modify 
or to cure even the more extreme distortions of childhood, still 
it is evident that this natural force is often ineffective in com- 
pleting the cure. Therefore, in doubtful cases at least, one should 
lend assistance in that class of patients likely to appreciate the 
advantage of symmetry over deformity, even though it be unat- 
tended by discomfort or disability. 

Genu Valgum. 

Synonyms. Knock-knee, in-knee. 

In the erect posture the thighs, whose upper extremities are 
separated by the pelvis and by the projecting femoral necks, 
incline slightly inward to the knees, forming an angle at the 
knee, opening outward, of about 172 degrees. This angle varies 
with the breadth of the pelvis, and it is, therefore, less in adult 
females than in males (Figs. 335 and 336). The internal condyle 
of the femur is slightly longer than the external ; thus the inclina- 
tion of the femur is compensated and the plane of the knee-joint 
is horizontal. 

1 New York Medical Record, July 30, 1887. 



DEFORMITIES OF BOXES OF LOWER EXTREMITY. 561 

When the inward projection of the knees is increased to a 
noticeable degree the tibiae are no longer perpendicular ; their 
upper extremities incline inward so that in the erect posture 
the feet are separated when the knees are in contact (Fig. 337). 
In the slighter grades of knock-knee, which are due in great 
degree to laxity of the ligaments, the deformity is apparent only 
when the weight of the body is borne, but in more marked cases, 
although the distortion is increased by the weight of the body, 
it cannot be overcome when this is removed, because it depends 
upon actual changes in the shape of the bones themselves. 

As has been stated, the normal inward inclination of the femur 
is compensated by the greater length of the internal condyle, and 



Fig. 335. 



Fig. 336. 





Female. Male. 

The normal inclination of the femora. (Pfeiffer.) 



in the deformity of knock-knee the plane of the knee-joint is 
still preserved by an apparent elongation of the inner condyle. 
Formerly it was supposed that there was an actual overgrowth 
of this part of the epiphysis, which caused the deformity, but the 
observations of Mikulicz and Macewen have shown that this 
apparent Lengthening is in reality due in great part to a deformity 
of the lower extremity of the shaft of the femur, which is so bent 
thai the epiphyseal line has an increased obliquity. And the 
hypothesis that bone grows more rapidly when relieved from 
weight and -train baa been disproved by Wolff, who has demou- 
i thai changes in the bones are the result of accommodation 
to altered function and attitude. (See page 235.) The deformity 



562 



ORTHOPEDIC SURGERY. 



is Dot limited to the femur ; in most instances there is a similar, 
although usually slighter, irregularity in the epiphyseal line of 
the upper extremity of the tibia, the shaft being so bent that 
when it is placed in the perpendicular position its internal con- 
dylar surface is higher than the external. In some instances the 
primary and principal deformity is of the tibia, the distortion 
being most marked in its upper third (Fig. 337). 



Fig. 337. 




Adolescent knock-knees. Deformity most marked in the tibiae. (See Fig. 340.) 



Changed Relation of the Femur and Tibia. In addition to the 
direct deformities of the bones there is a change in the relation 
of the femur to the tibia. The former is rotated inward and the 
latter is rotated outward. In some instances there is also a cer- 
tain degree of overextension at the knee. This is more often 
observed in the adolescent type, in which there is laxity of the 
Ligaments (Fig. 337). In the ordinary form of rhachitic knock- 
knee in childhood the habitual attitude is one of slight flexion 



DEFORMITIES OF BOXES OF LOWER EXTREMITY. 563 

at the knees, and in extreme cases there may be actual limitation 
of the range of extension at the knee, and at the hip as well. 

The Accommodative Attitude. When the limb is fully extended 
the deformity is most marked, because the shortened ligaments 
and tissues on the outer aspect of the joint become tense, and 
because the outward rotation of the tibia is increased. As the 
leg is flexed the deformity lessens, and in the attitude of complete 

Fig. 338. 




Skiagram of I • ving the deformity to be due to distortions of the diaphyses 

of the bones, while the epiphyses are practically normal. 



flexion it disappears (Fig. 340). This is explained by the fact 
that the posterior surface of the condyles is not affected by the 
deformity of the -haft, while the relaxation of the ligaments and 
the outward rotation of the femora allow the tibiae to become 
parallel with one another. This accounts for the habitual atti- 
tude of slight flexion which is so often assumed by patients who 
thus unconsciously accommodate themselves to the deformity. 



564 



ORTHOPEDIC SURGERY. 



Fig. 339. 



Secondary Deformities. The outward inclination of the leg 
throws more weight upon the inner border of the foot and tends 
to depress it into the attitude of valgus. Thus knock-knee in 
weak children is often accompanied by flat-foot, but in the more 

extreme grades of deformity 
the efforts of the patient to com- 
pensate for the abnormal sepa- 
ration of the feet may result in 
habitual supination ; in fact, 
confirmed and extreme knock- 
knee in older subjects is usually 
accompanied by a slight degree 
of varus that becomes very evi- 
dent after the correction of the 
deformity by operation. Even 
in the mildest type of knock- 
knee this compensatory and 
conservative effort of nature is 
shown by the so-called pigeon- 
toed walk, which is often the 
first symptom that attracts at- 
tention. 

Gait. The gait of the patient 
with well-marked genu valgum 
is peculiarly awkward and 
shambling. The knees " in- 
terfere," and must be assisted, 
as it were, in the effort to pass 
one another in walking. In the 
slighter cases the thigh is ab- 
ducted and rotated outward at 
the moment of passing its fel- 
low, the movement being then reversed as it, in its turn, supports 
the weight ; but in the more severe type this voluntary effort of 
the muscles of the leg is not sufficient, and, in addition, the body 
is swayed from side to side and the legs are alternately swung 
outward and lifted around one another. 

The deformity and the effects of the deformity on the gait and 
attitude a're the most important symptoms, as of other distortions 
of similar origin. The patient is, as a rule, easily fatigued, and 
pain during the progressive stage, referred to the inner side of 
the knee, where the ligaments are subjected to continuous strain. 




Deformity of the femur in genu valgum. 
(Mikulicz.) 



DEFORMITIES OF BOXES OF LOWER EXTREMITY. 565 

is a common symptom, particularly in the adolescent type of 
genu valgum. 

Unilateral Knock-knee. This description refers particularly to 
the cases in which the deformity is bilateral. Xot infrequently 
it is unilateral, the limb being so shortened by the distortion that 
a well-marked limp replaces the swaying gait. The pelvis is 
tilted toward the short limb, while the body is inclined in the 
opposite direction, thus in cases of long standing a permanent 
curvature of the lumbar spine may be present. 

Fig. 340. 




Adolescent knock-knee, showing the disappearance of the deformity when legs are flexed. 

(See Fig. 337.) 

Knock-knee Combined with Bow-leg and with General Rhachitic 
Distortions. Occasionally the unilateral knock-knee may be 
accompanied by an outward bowing of its fellow; and in the 
marked distortions of 'the lower extremity, induced by rhachitis, 
the bones may be twisted and bent in various directions, although 
•it ward expression of the deformity may be genu valgum. 
For example, the femora may be bent forward and outward 
above and inward and backward below, while tin; tibia- may 
be bent inward above and outward and forward below. 

In other instances, especially in the slighter rhachitic deformi- 
mtward bowing of the leg may accompany a Blight 
::<". so thai it may be difficult t<> classify 
tie- deformity. 



566 



ORTHOPEDIC SURGERY. 



In the more extreme deformities of the rhachitic type the 
shape as well as the contour of the bones is markedly modified, for 
example, the internal border of the tibia may become very prom- 
inent at its upper extremity, and may project beneath the skin 
like an exostosis (Fig. 341). A change in the contour of the 
fibula accompanies and corresponds to that of the tibia, although 



Fig. 341. 




Knock-knee and bow-leg. 

it is, as a rule, much less pronounced. As has been stated, the 
internal structure or architecture of the affected bones is changed 
to accommodate the new static conditions, and according to 
Wolff the internal change precedes the external deformity. 

Pathology. In knock-knee due directly to rhachitic the 
changes in the bones and in the epiphyseal cartilages are char- 



DEFORMITIES OF BOXES OF LOWER EXTREMITY. 567 

acteristic of that affection, but in the milder grades of deformity, 
aside from the change in the contour of the bones, the trans- 
formation of the internal structure, and in some instances slight 
thickening or irregularity of the epiphyseal cartilages, there is 
little noteworthy change from the normal (Fig. 339). The 
tissues on the internal aspect of the joint are relaxed ; those on 
the outer side, the lateral ligaments, the capsule and the biceps 
muscle, are contracted and resist the reduction of the deformity. 
In the interior of the joint slight changes in the articulating sur- 
faces of the bones, and evidences of chronic irritation of the 
synovial membrane have been described. 

Measurements. There are various methods of measuring the 
deformity. One of the simplest and most practical is to trace 
the outlines on paper, while the child is seated with the limbs 
fully extended, the knees being sufficiently separated to allow 
the pencil to pass between them. The increase of the deformity, 
depending upon the laxity of the ligaments and upon the outward 
rotation of the tibiae, may be estimated by measuring the distance 
between the two internal malleoli when the patient stands, the 
knees being slightly separated as before, and comparing this 
measurement with that between the similar points in the tracing. 

In the early stage of progressive knock-knee, particularly in 
the type not caused directly by rhachitis, laxity of ligaments 
and the habitual assumption of the attitude of rest will account 
for the deformity, which the patient may be able to overcome, in 
irivut degree at least, by voluntary effort. This voluntary control 
of the deformity is very suggestive, as indicating certain factors 
in it- etiology, and the principles that should be followed in its 
treatment. 

Treatment. The treatment of the deformity under considera- 
tion may be classified as expectant, mechanical, and operative. 

Expectant treatment should not be expectant in the sense that 
nothing i- to be done to correct the deformity, but expectant in 
that more positive treatment by braces or by operation is delayed 
or avoided if it prove- to be unnecessary. 

I Miring this period the predisposing cause of the deformity, if 
it La constitutional, should receive proper dietetic or medicinal 
treatment^ a- already described in the chapter on Rhachitis. 
An-I. if possible, the direct exciting causes of the deformity must 
be removed — that Ifl to Bay, the improper attitude-, or, in the 
adolescent, the predisposing occupations should he discontinued. 
General m -- _ >f the limbs may he employed with advantage ; 



568 



ORTHOPEDIC SURGERY. 



in older children special exercises may be practised, and in all 
cases, whether braces are used or not, direct manipulation of the 
distorted limbs is of the first importance. 

Manipulation. The limbs should be vigorously massaged at 
morning and night, and forcibly straightened. The latter pro- 
cedure is conducted as follows : The patient is seated in a chair, 



Fig. 84?. 



Fig. 343. 





The Thomas knock-knee brace. 



Thomas knock-knee braces with pelvic band. The 
pelvic band may be divided also, the two parts being 
joined by straps (Fig. 344). 



the limb being fully extended so that the deformity is made as 
extreme as possible. One hand then clasps the knee, the pal in 
lying against its inner aspect ; with the other the calf is grasped 
firmly and the leg is then gently straightened over the fulcrum 
formed by the palm of the hand, and is held in the corrected 
position for a moment. This manipulation should be continued 



DEFORMITIES OF BOXES OF LOWER EXTREMITY. 569 

with gradually increasing force, although not to the extent of caus- 
ing actual pain, for ten minutes at least twice in the day and 
oftener if possible. 

Posture and Exercise. It has been stated that genu valgum is 
often accompanied, especially in the rhachitic cases, by flat-foot, 
while in another type the inversion of the feet, or in the more 

Fig. 344. 




Modified Thomas knock-knee braces applied. 



cases the actual fixed attitude of varus, indicates the effort 
of nature to withstand and to compensate for the deformity at 
the knee. This serves as an indication for making the soles of 
the shoes thicker on the inner border, as in the treat incut of flat- 
foot, in order to throw the strain upon the outer border of the 
foot. The patient should be instructed to walk with the feet 



parallel with one another, and for older children the tip-toe exer- 
cises, in which the body is raised upon the toes as many times 
as the strength permits, or games or exercises in which the legs 
arc extended should be encouraged. Such exercises are often 
efficacious in the early stage of adolescent knock-knee, for, as 
has been mentioned, genu valgum is an exaggeration of the atti- 
tude of rest ; therefore, its progress should be checked by the 
assumption of the attitudes proper to activity. Bicycle, and 
particularly horseback, riding may be recommended also in this 
class of cases. A careful record of the deformity should be kept 
during this tentative treatment, and if it improves somewhat one 
is justified in delaying the more radical measures. This question 
may be decided, as a rule, in three months if instructions are 
faithfully followed. 

Treatment by Braces. The most efficient brace for the treatment 
of genu valgum is the simple straight steel bar or splint extend- 
ing from the trochanter to the heel of the shoe, without joint at 
the knee. The greater efficacy of the rigid bar as compared with 
the jointed brace is explained by the fact that the rectifying 
force acts constantly when the joint is fixed, and because, in many 
instances, the patient habitually flexes the knees so that direct 
pressure cannot be made upon the deformity by a brace that 
allows this attitude. 

The Thomas Brace. The simplest and cheapest brace is 
that of Thomas, which consists of a light steel bar provided with 
a pad at its upper end for pressure against the trochanter, while 
the lower, rounded extremity is turned inward at a right angle, 
to pass through the heel of the shoe. The knee is fixed by a 
posterior bar attached to a thigh and calf band, as illustrated in 
the figure. When the brace is applied the knee is drawn back- 
ward and outward and is attached firmly to the brace by a roller 
bandage (Fig. 342). 

In the more extreme cases in which the knees and thighs are 
habitually flexed, the addition of a pelvic band attached to the 
uprights by a free joint at the hips adds to the comfort and 
efficiency of the apparatus, as the attitude of outward or inward 
rotation can be regulated by twisting the uprights slightly. Or 
the pelvic band may be divided and attached by means of straps 
on the front and back. The uprights may be bent somewhat 
inward at first, and as the legs become straighter they are 
straightened and finally bent slightly outward to allow for the 
overcorrection of the deformity (Fig. 344). Twice a day the 



DEFORMITIES OF BOXES OF LOWER EXTREMITY. 571 



Fig. 345. 




XU 



braces should be removed to allow for massage, manipulation, 
and for voluntary exercises of the limbs. In most cases the 
braces are not employed at night, although the rectification of 
the deformity may be hastened by their constant use. 

If the deformity is unilateral so that a brace is required for one 
limb only, the other shoe should be raised by a cork sole about 
three-quarters of an inch in thick- 
ness, to make walking easier. 
Children soon become accustomed 
to the braces and walk easily in 
spite of the absence of joints at 
the knees. 

Another simple and efficient 
brace is that used at the Children's 
Hospital at Boston (Fig. 345). 
The upper part of the brace is 
turned backward and upward to 
lie against the buttock, and the 
feet can be rotated in or out by 
lengthening or shortening straps 
passing before and behind the 
body. Braces jointed at the knee 
are sometimes employed, but they 
are, as a rule, ineffective except 
in the slighter cases in which the 
deformity depends upon laxity of 
ligaments rather than distortion 
of bone. 

Duration of Treatment by 
Braces. The duration of the 
brace treatment depends, of course, upon the degree of deformity, 
the age of the child, and upon the efficiency of the apparatus. 
From six months to one year of treatment by this means is 
usually required. The cure is assured by the gradual adaptation 
of the parts to the new static conditions. The contracted tissues 
of the outer aspect of the joint become lengthened ; the lax liga- 
ments on the inner side contract ; the internal structure of the 
condyles and of the adjoining diaphysis i- gradually transformed 
and at the external contour of the bone becomes correspondingly 
straighter. When the braces an- discarded attention should be 
paid to the attitudes, and the exercises that have been mentioned 
should be continued in order that relapse may be prevented. 




Long braces for genu valgum. 
(Bradford and Lovett.) 



672 ORTHOPEDIC SURGERY. 

The Plaster Bandage. When the bones are yielding, as 
in the deformity in young children, it may be corrected rapidly 
by the repeated applications of plaster bandages, the limbs being 
straightened as far as possible without causing discomfort at each 
sitting, or it may be corrected at once under the influence of 
anaesthesia, which is the better method. 

Operative Treatment. Immediate correction of the deformity, 
when it is at all marked, is, as a rule, indicated after the age of 
four or five years, and is a satisfactory treatment at any age 
except during the period of active rhachitis. It is perhaps 
needless to remark that the necessity for operation implies 
neglect of proper preventive treatment or the failure of the 
manipulative and mechanical methods, because of their im- 
proper application. While it is possible to correct deformity 
of the bones by mechanical treatment in cases far beyond this 
limit of age, yet the time required and the discomforts of the 
treatment exclude it in all but very exceptional cases. 

Osteotomy. At the Hospital for Ruptured and Crippled 
osteotomy is usually performed in the treatment of genu valgum 
by means of the small Vance osteotome, the so-called " sub- 
cutaneous osteotomy " (Fig. 316). 

The limb having been prepared in the usual manner is semi- 
flexed, and the inner surface of the knee is placed on a firm sand- 
bag. With the fingers the femur is firmly grasped just above 
the condyles, so that its size and position may be accurately 
determined, and the sharp osteotome about the size of a lead- 
pencil is forced with its cutting edge parallel to the axis of the 
thigh down to the bone, at a point about one and a half inches 
above the external tuberosity. While it is held firmly in position 
against the bone it is turned to the transverse direction and is 
then driven through the cortex. When it enters the medullary 
canal, as is made evident by the lessened resistance, it is partly 
withdrawn and moved slightly to one side and the other, and 
driven through the cortical substance until by gentle force the 
bone may be fractured. The osteotome is then withdrawn ; the 
minute wound is covered with a pad of dry gauze, or, if the 
oozing is profuse, it may be closed with a catgut suture. The de- 
formity is then overcorrected sufficiently to simulate well-marked 
genu varum, and a plaster spica bandage is applied. If the defor- 
mity is bilateral both limbs are operated upon at the same sitting. 

The plaster bandage is continued for from four to six weeks, 
and it is then usually supplemented by a brace, which may be 



DEFORMITIES OF BOXES OF LOWER EXTREMITY. 573 

worn with advantage for several months, because of the laxity 
of the ligaments of the knee-joint, which usually accompanies 
extreme deformity of rhachitic origin. In less marked cases and 
in older subjects the support is unnecessary. Massage and 
exercises during the stage of recovery should be employed if 
possible. 

Incomplete osteotomy and fracture in the manner described 
has been employed at the Hospital for Ruptured and Crippled in 
a very large number of cases without a single unfavorable result. 
The discomfort is insignificant, and confinement to the bed after 
the third day is unnecessary. 

Cuneiform Osteotomy. In the more extreme cases of 
general rhachitic deformity of the lower extremity in which the 

Fig. 346. 




The Grattan osteoclast. 

tibia is implicated, it is sometimes advisable, in addition to the 
osteotomy of the femur, to remove a cuneiform section of bone 
from the inner side of the tibia just below the epiphysis, in order 
to -traighten the leg completely. In such cases it is better to 
perform the second operation at a later time, in order that the 
effect of the femoral osteotomy may be observed. In exceptional 
the deformity may be practically confined to the tibia ; in 
such instances it should be corrected by a primary cuneiform or 
Linear osfc otomy. 

( Ki k LASX8. Osteoclasis, by means of the Grattan osteoclast, 
is an effective operation. With this instrument the bone may be 
broken above the condyles at the desired point. The lower 
resistant bar La applied over the external condyle, the upper 



574 ORTHOPEDIC SURGERY. 

about four inches higher. The limb is then firmly fixed by the 
hands of an assistant, and the breaking bar is screwed rapidly 
home, breaking or bending the bone at the point of election. 
The deformity is then overcorrected in the manner described. 
]Sot infrequently in rhachitic cases the principal or primary dis- 
tortion is of the tibia. In such cases the correction is made at 
this point. If it is necessary to operate upon both the femur 
and the tibia the osteoclast, which bends and breaks, is to be 
preferred to osteotomy. 

The adolescent type of genu valgum is not often extreme. 
As a rule, the deformity of the bone is of comparatively short 
duration, and it is accompanied by considerable laxity of liga- 
ments. In the more chronic cases the osteotomy above the 
condyles may be performed in the manner described, but in 
Berlin and Vienna, where the deformity is more common than 
in Xew York, other procedures are often employed. 

Wolff's Treatment. One method is that of Wolff, who by 
means of the " Etappen Verband " gradually corrects the deformity . 

The patient is anaesthetized, and the limb, having been care- 
fully protected with cotton, particularly so about the malleoli, 
the patella, and the inner condyle, is enveloped in a firm plaster 
bandage reaching from the malleoli to the pubes. When the 
plaster begins to harden one assistant steadies the pelvis, another 
holds the inner condyle, while the operator draws the leg 
inward with moderate but persistent force against the fulcrum 
formed by the hand of the second assistant, and holds it firmly 
in the partly corrected position until the bandage is firm. About 
three days later a wedge-shaped section of the bandage about one 
inch in width is removed from the part that covers the inner 
half of the knee, the outer half of the bandage being simply 
divided. The leg is then forced inward until the two sections 
are again brought into contact. The position is retained by an 
additional plaster bandage about the weakened part. This pro- 
cedure is repeated at intervals until the leg is completely 
straightened — a result that is often accomplished in two weeks. 
Xo anaesthetic is required for the secondary corrections. When 
the deformity has been corrected the patient is allowed to walk 
about, and for convenience the plaster bandage is divided iuto a 
thigh and leg part, which are attached by lateral joints incor- 
porated in its substance so that motion is allowed. This 
apparatus must be worn for several months, and is, of course, to 
be supplemented by massage and exercises. 



DEFORMITIES OF BOXES OF LOWER EXTREMITY. 575 

Loeexz's Operation. Another means of correction of de- 
formity without open operation is that employed by Lorenz, 
what he calls " Intra-articnlare modelirerende redressemeut." 
In this operation the deformity is reduced under anaesthesia 
at one sitting by the gradual application of force by means of 
the Lorenz osteoclast. The reduction depends partly upon the 
stretching of the external ligaments and partly upon the actual 
bending of the diaphysis of the bone, as in the Wolff method, 
and sometimes upon actual separation of the epiphysis. 

TThen the limb has been straightened, or somewhat overcor- 
rected even, a long plaster bandage is applied which is worn for 
six weeks and is then replaced by a jointed walking brace to 
be worn for about a year. The operation is not attended by 
severe pain, and the patient is usually allowed to walk about in 
a few days. 

Genu Varum. 

Synonym. Bow-leg. 

The term bow-legs includes, in its popular sense, all the dis- 
tortions that cause a separation of the knees when the ankles are 
in contact with one another. But, strictly speaking, genu varum 
is the reverse of genu valgum — that is, the principal distortion is 
at or near the knee-joint — while bow-leg, as the name implies, 
is a simple bowing of the tibia and fibula, as a rule near the 
ankle-joint (Fig. 347). In true genu varum a line dropped 
from the head of the femur falls inside the kuee (Fig. 333) ; the 
inner condyle of the femur and the inner tuberosity of the tibia 
bear the greater part of the weight ; the outer condyle is on the 
same level or somewhat lower than the internal, and the outer 
tuberosity of the tibia may be somewhat higher than the internal. 
The femur is abducted and rotated outward ; the tibia is rotated 
inward. These changes, it will be noted, are the reverse of those 
found in genu valgum. As has been stated, the deformity of 
genu valgum disappears when the legs are flexed, and in genu 
varum, if the legs are flexed and the knees are placed in contact 
with one another, the malleoli may be actually separated, simu- 
lating the deformity of knock-knee (Fig. 348). This is explained 
by the inward rotation of the femora, necessitated by placing the 
knees in contact with one another. 

In genu varum the distortion of the bones is not as strictly 
'•oiitined to the neighborhood of the knee-joint as in genu valgum, 
and in simple bow-leg there i- almost always a certain amount of 



576 



ORTHOPEDIC SURGERY. 



distortion at the knee, dependent, in part, upon laxity of the 
Ligaments. It is proper, therefore, to use the two terms 
synonymously, although one must recognize a decided difference 
between the genii varum type, in which the deformity is greatest 
at the knee, and which is accompanied, as a rule, by marked 



Fig. 347. 



Fig. 348. 





The genu varum type of bow-legs, showing 
the outward rotation of the femora. 



The same patient, showing the separa- 
tion of the malleoli when the knees are in 
contact. 



laxity of the ligaments (Fig. 333), and the bow-leg type, in which 
the deformity may be strictly confined to the lower third of the 
leg (Fig. 353). 

Symptoms. As was said of genu valgum, the deformity is 
the principal symptom. The gait is somewhat rolling, because 



DEFORMITIES OF BOXES OF LOWER EXTREMITY. 577 

each foot must describe a part of the arc of a circle before reach- 
ing the ground ; and because of the inward rotation of the tibiae, 
or because of the inward spiral twist of the bone that is some- 
times present, patients often toe-in in walking. 

Except in extreme cases the weakness and awkwardness char- 
acteristic of genu valgum are absent. This may be explained by 
the fact that the relation of the bones is such that the general 
attitude is one of activity, the weight falling on the outer side of 
the feet ; thus flat-foot is uncommon as an accompaniment of bow- 
leg, except in the early or rhachitic type. 



Fig. 349. 




Genu varum of rhachitic origin in an adult. 



Measurements. The full effect of the deformity appears only 
when the weight of the body is borne, but for practical purposes 
the tracing of the extended legs is the best method of recording the 
axed deformity. In true genu varum the deformity is greatest 
at the knee, and in the distortion the apposed surfaces of the 
femur and ol the tibia participate. 

In simple bow-leg the deformity may be confined to the tibia, 



578 



ORTHOPEDIC SURGERY. 



Fig. 350. 



which, in addition to the outward bowing, may be twisted inward 
somewhat upon its long axis. 

Genu varum may be unilateral or it may be combined with 
genu valgum of its fellow (Fig. 341 ), and occasionally slight 
knock-knee and slight bow-leg may be present in the same limb. 
Treatment. Expectant Treatment. The slighter cases of bow- 
leg in early childhood may be treated by manipulation. The 

leg, grasped firmly at the ankle and 
at the knee, is straightened with a 
certain amount of force over and 
over again. Gradual correction by 
this means may be hastened by mak- 
ing the sole of the shoe slightly 
thicker on the outer border. This 
aids also in correcting the secondary 
pigeon-toe, but if the foot is weak, 
as it usually is in rhachitic cases, 
this method should not be employed, 
as it might induce flat-foot. 

Treatment by Braces. If the de- 
formity is more extreme, or if im- 
provement does not follow expectant 
treatment, apparatus should be em- 
ployed. If the distortion is confined 
to the lower third of the tibia, a 
Knight brace may be used. It con- 
sists of two uprights attached to a 
foot plate ; the inner bar is provided 
with a pad at its upper end for 
pressure on the internal condyle of 
the femur. The outer bar reaches to the head of the fibula, 
and the two are joined by a calf band. When applied the leg is 
drawn toward the inner upright by means of a lacing, which 
passes about it within the outer bar. When the lacing is made 
fast, the outer bar is bent toward the leg, and thus it aids some- 
what in supporting it in an improved position. The foot plate 
may be dispensed with, and the brace may be attached to the 
shoe, and even the outer bar may be removed, leaving only the 
upright, which is held in position by the lacing. The apparatus, 
then, has the appearance of a gaiter, and has the advantage 
of being inconspicuous, although somewhat less effective than 
the Knight brace. By this apparatus, combined with vigorous 




Long braces for genu varum. 
(Bradford and Lovett.) 



DEFORMITIES OF BOXES OF LOWER EXTREMITY. 579 

manipulation, the deformity may be corrected, in young children, 
in about six months. 

If the outward bowing of the knee is marked, another form of 
apparatus will be necessary, and its effectiveness will be much 
increased if there is no joint at the knee. The outer bar, shaped 
to the contour of the leg, is attached above to a pelvic band and 
below to a foot plate, as is the short brace. An inner straight 
bar extends to the upper third of the thigh, and is attached to 
the outer bar by a thigh band. This inner upright is provided 
with a lacing of leather or canvas, similar to that of the short 
brace, which surrounds the knee and upper part of the leg, and 
thus draws it toward an improved position. The outer bar is 
then bent slightly inward and serves as an additional support. 
Another form of apparatus consists of a single upright, attached 
to the shoe and extending upward as high as possible on the 
inner aspect of the thigh. At its upper extremity a pressure pad 
is placed and the knee is drawn toward it by means of straps 
or bandages. 

An unproved brace of this kind is that in use at the Boston 
Children's Hospital, in which the upper part of the upright is 
curved upward and outward just below the groin, to a point on 
a level with and behind the trochanter, and is attached to its 
fellow by means of a strap passing across the buttocks so that 
the feet may be somewhat rotated outward if necessary (Fig. 
350). 

Operative Treatment. In children more than five years of 
age, and in cases of the more extreme type at an earlier age, or 
when the opportunity for mechanical treatment is lacking, imme- 
diate correction of the deformity is indicated. Either osteoclasis 
or osteotomy may be employed, and in some instances manual 
force is sufficient for the correction of the deformity. There is 
but little choice between the methods. Osteoclasis is somewhat 
safer possibly, and i- t<> be preferred for the younger patients. 

At til-- Hospital for Ruptured and Crippled, osteotomy is 
almost always performed. The small osteotome is inserted on 
the inner aspect <>f the tibia at the point of greatest deformity, 
and when the bone has been sufficiently weakened the fracture is 
completed by manual force. The fibula may be broken at the 
same time, or, a- is usually the case, it may be -imply bent out- 
ward. Tie- deformity is overcorrected, and a well-fitting plaster 
bandage, including the foot and extending to the trochanter, i- 

applied. 



580 



ORTHOPEDIC SVlKiERY. 



Fio. 351. 



The patient usually remains in bed for a few days ; he is then 
dressed, and if lie so desires is allowed to stand. Almost no pain 
or discomfort follows the operation, and, in fact, in properly 
selected cases, it is not only free from danger, but it has a very 
decided advantage over the simple mechanical treatment. If the 
child is in good condition, and if the deformity is overcorrected 
at the time of operation, apparatus will not be required in the 
after-treatment ; but in many instances some form of support is 
indicated, usually because slight deformity, due to laxity of liga- 
ments or to deformity of the femur, appears when the weight of 
the body falls upon the legs. 

It has been stated that the deformity of bow-leg depends in 
part upon a distortion of the femur as well as of the tibia. As 
a rule, the correction of the greater deformity of the tibia will 

be sufficient, but in more 
extreme cases a secondary 
osteotomy above the con- 
dyles will be necessary. 
This may be performed 
simultaneously with that on 
the tibia, but it is better to 
defer it until the effect of the 
primary operation has been 
observed. 

Anterior Bow-leg. 

Synonym. Anterior cur- 
vature of the tibia. 

Both bow-legs and knock- 
knees are often seen in chil- 
dren who present no signs 
of general rhachitis, but anterior bowing of the legs is almost 
always combined with general rhachitic distortions of the lower 
extremity, most often with knock-knees ; these in turn are 
caused by marked distortion of the femora, which may be bent 
forward and outward above, and inward at their lower extremi- 
ties, " corkscrew deformity." In anterior bow-legs the tibia? are 
usually flattened from side to side, curved inward or outward 
and bent forward, the projecting crests presenting sharply beneath 
the skin. 

Symptoms. The effect of the anterior bowing is to throw the 
weight forward upon the foot; thus the heels appear abnormally 




Anterior bow-legs. 



Fig. 35-J 




Long anterior curvature of the tibia and flat-foot. 
Fig. 353. 




Khachitic anterior bow-legs. 



582 ORTHOPEDIC SURGER Y. 

long and prominent, and the patient seems to sink forward at 
each step (Fig. 353). The knees are usually somewhat flexed, 
partly as the effect of knock-knee, with which the deformity is 
usually combined, and the feet are, as a rule, flat. As has been 
stated, anterior bowing is almost never seen as an independent 
deformity unless it is a relic of the more general distortion which 
has been " outgrown." 

Treatment. Anterior curvature of the tibia must, as a rule, 
be treated by operation. After complete fracture of the tibia 
and fibula, the deformity may be overcome by forcing the bones 
directly backward. In many instances tenotomy of the tendo 
Achillis may be required. Cuneiform osteotomy of the tibia 
permits more perfect correction, but the final result is equally 
good after simple osteotomy or osteoclasis, and if one succeeds in 
separating the posterior part of the tibia so that it may conform 
to the straightened anterior border an actual elongation may be 
obtained. 

General Rhachitic Distortions. 

General rhachitic distortions of the lower limbs have been 
mentioned in connection with knock-knee and with anterior 
bow-leg. A more extended description is hardly necessary. 
The deformities are usually of the knock-knee type, and they 
may be treated on the same general plan that has been outlined 
in the description of the less extreme distortions. 



CHAPTER XVII. 

DISEASES OF THE NERVOUS SYSTEM. 

From the orthopedic standpoint only those diseases that 
directlv interfere with the function of locomotion or that cause 
deformity and for which local treatment is of benefit are of 
special interest. Even this limited class is not often seen in 
the early or progressive stage, and it is rather with the effects of 
a disease that is no longer present than with the disease itself 
that the orthopedic surgeon is especially concerned. 

The relative importance of this branch of orthopedic work may 
be illustrated by the statistics of the Hospital for Ruptured and 
Crippled. In a period of ten years — 1890-1899 — 42,124 new 
patients were examined in the out-patient department. Exclud- 
ing cases that cannot properly be classed as orthopedic, 38,419 
remain. In 2441 of these the nervous system was involved (6.3 
per cent.) ; 2028 of the cases were in young children ; 413 of 
the patients were more than fourteen years of age, and of this 
number 266 were adults. 

Anterior poliomyelitis furnished about 75 per cent, of the 
total number. In 20 per cent, the cerebrum was involved, and 
5 per cent, were miscellaneous cases. In 611 cases treated in a 
period of about two years there were 463 cases of poliomyelitis, 
121 cases of paralysis of cerebral origin, 16 cases of obstetrical 
paralysis, 4 cases of pseudohypertrophic muscular paralysis, and 
7 miscellaneous cases. These statistics will explain the selection 
of diseases of the nervous system for consideration and the order 
in which they are described. 

Acute Anterior Poliomyelitis. 

Synonym. Infantile paralysis. 

Pathology. Anterior poliomyelitis is an acute inflammatory 
process of tic* area of tic gray matter of the anterior cornua sup- 
plied by tic anterior spinal arteries. It involves both the neu- 
roglia and the cells, and it resulte in degeneration and atrophy 
of tic- interstitial tissue and of tic ganglion cells. 1 

1 Starr, Loomls-Thompw .>f Practical Medietas. 



584 



ORTHOPEDIC SURGERY. 



Ill the acute febrile form, comprising about three-fourths of 
the cases, there is an actual inflammation ; in the other type in 
which the paralysis is of sudden onset unaccompanied by consti- 
tutional evidences of disease, the symptoms may be caused by 
hemorrhage or by thrombosis. 

The minute changes in the cord are characteristic of inflamma- 
tion, distended bloodvessels, minute hemorrhages, infiltrating 
leucocytes, and serum. In the early stage the motor cells become 
cloudy in appearance, later they are swollen and lose their distinct 
outlines. The degenerative changes affect both the cells and 
neuroglia ; the affected gray matter shrinks and the nerve fibres 
atrophy, and the cord becomes distinctly smaller at the seat of 
the disease. When the motor conductivity of the cells is cut off, 
the muscles which are supplied by them are paralyzed and waste 
away. The circulation in the affected parts is impaired, con- 
tractions and distortions appear, and growth is retarded. 

Etiology. The etiology of the disease is obscure. Exposure to 
heat, sudden chilling of the body, overfatigue, injury and the like 
are thought to be predisposing causes. The direct cause of inflam- 
matory disease of the cord is supposed to be some form of infection. 

The disease affects the sexes in nearly equal numbers, and 
those in perfect health as often as those whose resistance is 
enfeebled. It sometimes occurs in epidemics, and there are 
instances in which several members of the same family have been 
affected, but usually the cases are isolated and no adequate cause 
for the disease can be assigned. 

Age. Acute anterior poliomyelitis is essentially a disease of 
infancy. This is illustrated by the combined statistics of several 
observers tabulated by Starr. 1 





c 


Fh 


h - 










. 


t- 


ti 




a 


03 


CS 


C3 


03 


03 




03 


03 


03 




















0> 


4; 




k-> 


>, 


>. 


>, 


>t 


t>> 


>> 


>> 


>, 


>> 




4j 


T3 




S3 


1 •& 


S3 


S3 


S3 


si 


S3 




























CO 






CO 


t> 


00 






Seeligmaller . 


20 


25 


18 


1 


1 


2 














Galbraith 


17 


38 


15 


4 


1 

















Sinkler .... 


44 


92 


55 


29 


9 


2 


3 


6 





3 


Gowers .... 


21 


21 


25 


9 


17 


4 


2 


6 


4 





Starr .... 


16 


38 


27 


9 


10 


4 
~12~ 


2 


2 


4 


3 




118 


214 


140 


52 
cent. 


i 38 


7 


14 


8 


6 






172, or 77 per 


before 


Ihefo 


urth y< 


l&T. 





It is far more common during the warm months than at other 
seasons, as is illustrated in 452 cases tabulated by Starr. 2 



Loomis-Thomrson. System of Practical Medicine. 



2 Loc.cit. 



Disi; asks OF THE NERVOUS SYSTEM. 585 

January 8 

February 5 

March 20 

April 9 

May 18 

June 49 1 327, or 72 per cent., 

Tulv 97 I during the four 

August .......... 116 | months, June to 

September 65 J September. 

October 42 

November 11 

December 12 

452 

Distribution of the Paralysis. The lower extremities are far 
more often paralyzed than the upper. In 41 6 of 595 cases, 
tabulated by Starr, the paralysis was limited to the lower extrem- 
ities, as contrasted with 53 cases in which the upper extremities 
were alone involved. 

Duchenne, Secligmuller. Sinkler. Starr. Total. 

Both legs .... 9 14 107 40 170 

Right leg .... 25 15 63 20 123 

Left leg 7 27 62 27 123 

Right arm .... 5 9 5 7 26 

Left arm 5 4 8 4 21 

Both arms .... 2 1 1 2 6 

All extremities ... 5 2 35 5 47 

Arm and leg same side .1 2 26 4 33 

Arm and leg opposite sides .2 1 14 8 

Trunk 1 22 3 26 

Three extremities ... 10 2 12 

62 75 340 118 595 

Symptoms. The disease is usually divided into several stages : 

1. The stage of onset. This is usually attended by constitu- 
tional symptoms, by fever and headache, even by convulsions 
and delirium ; by vomiting and intestinal disturbance, or occa- 
sionally by Bevere pain. In most instances the elevation of the 
temperature is not extreme, nor is the constitutional disturbance 
". and but for the paralysis the attack would be considered 
Bfl one of the ordinary illnesses so common in childhood. In 
-nine eases, however, the fever is high, and there may be con- 
vulsions and prolonged unconsciousness, while in others there 
may be do premonitory symptoms whatever; the child is appar- 
ently well at nighty but waken- in the morning paralyzed. 

In many instances the weakness or paralysis caused by anterior 
poliomyelitis of a mild type is not discovered until the child 
- to walk, when the awkward gait, or limp, or the distortion 
of a f<».,r. may make it evident 

In a few hour- or a few days after the first symptoms of the 
->• tie- paralysis appears ; it- area may extend slowly after 



586 ORTHOPEDIC SURGER Y. 

it is recognized! or its extreme limit may be reached at once. 
This original paralysis is always greater than that which finally 
persists. The duration of the first stage may be from a few 
hours to a week. 

2. Then follows a stationary period, lasting from a week to a 
month ; the constitutional symptoms cease, but the paralysis 
remains. 

3. This is succeeded by the stage of partial recovery, lasting 
from one to six months or longer. The muscles which were 
paralyzed because of the secondary congestion and exudation 
about the local myelitis, recover their power in whole or in part, 
while those muscles supplied from the area in the cord in which 
the nerve cells have been destroyed, waste away. At this time 
the contractions and distortions in the paralyzed limbs appear. 

4. The chronic stage. This may be considered to last until 
adult age or until the ultimate damage to the individual, due to 
the retardation of the growth and unbalancing of the mechanical 
equilibrium of the body may be summed up. 

The sensation of the paralyzed part is not affected except in 
the extreme cases. The temperature is lower from the first. In 
many instances the limb is not only cold, but it is congested and 
blue. These circulatory disturbances are caused primarily by 
the interference with the vasomotor system, but they are con- 
firmed later by the atrophy of the muscles and by the permanent 
contraction of the bloodvessels. Thus, in general, the impair- 
ment of the circulation corresponds to the degree of the paralysis, 
but not absolutely so. In certain cases the paralysis may be 
limited in extent, and yet the limb may be cold and congested, 
while in others in which the loss of power is much greater the 
temperature is but slightly lowered and the color remains 
normal. The same is true of retardation of growth. In most 
instances the ultimate shortening of the limb corresponds to the 
degree of the paralysis and consequent loss of function ; but 
occasionally cases are seen in which the growth is markedly 
retarded, although but few of the muscles are paralyzed. 

Diagnosis. It is doubtful if the diagnosis of acute anterior 
poliomyelitis could be made before the stage of paralysis. But 
after the paralysis has appeared there should be little difficulty 
in interpreting the symptoms. It is a disease usually of acute 
onset, followed by paralysis of certain muscular groups or of 
entire members. It is a flaccid paralysis, the reflexes are lost, 
the muscles no longer contract under faradism, and the reaction 



DISEASES OF THE NERVOUS SYSTEM. 587 

of degeneration sood appears ; the tissues waste, and the circula- 
tion is impaired in the affected parts. 

It is usual to consider, first, in differential diagnosis the paralyses 
of cerebral origin, but this is more for the purpose of calling 
attention to the essential differences between the two than because 
they are likely to be confounded by one acquainted with the 
ordinary characteristics of cerebral and spinal disease. 

Paralysis of Cerebral Origin in Childhood. In paralysis of cere- 
bral origin the common form is hemiplegia. It usually follows 
convulsions, and the intelligence may be impaired. The paralysis 
is not complete, nor is it limited to groups of muscles ; it is 
rather powerlessness or impairment of function, due to loss of 
cerebral control. The reflexes are increased and limbs are 
stiffened, not flaccid. The electrical reactions are not lost or 
changed in quality. Paralysis of cerebral origin may be also 
paraplegic or diplegic in its distribution, but in these cases the 
general characteristics are the same as in the hemiplegic form, 
except that the intelligence is more markedly affected. 

Other Forms of Spinal Paralysis. Transverse myelitis is very 
uncommon in childhood. In this disease the distribution is 
equal, the reflexes are at first increased, and sensation as well as 
motion is lost. 

Pott's Paraplegia. In this form of paralysis, also, the distribu- 
tion is equal, the reflexes are increased, and the signs of the 
disease of the spine are always present. 

Spastic Spinal Paraplegia. In this as in the preceding form 
the distribution is equal, and the reflexes are exaggerated. 

Rheumatism and Joint Disease. In orthopedic practice anterior 
poliomyelitis is not often seen in the stage of onset unless pain 
i- ;i prominent symptom, when the disease may be mistaken for 
rheumatism or for some form of joint disease. Cases of this 
type an- not uncommon. The muscles are sensitive to pressure 
and the movements of the joints cause discomfort. In certain 
instances the paralysifl may not be apparent on the first examina- 
tion ; when it does appear the diagnosis is, of course, established ; 
therefore, the characteristics of diseases of the joints need not be 

• It-tailed. 

Multiple Neuritis. Multiple neuritis is usually a sequel of 
infectious diseases, or <>f metallic poisoning. In the cases due to 
metallic poisoning with lead or arsenic the paralysis usually begins 
in the extensors "f the hand- and feet, and i- symmetrical in Its 
distribution. This is true, also, of the Localized forma of paralysis 



588 ORTHOPEDIC SURGER Y. 

following contagious diseases in which the dorsal flexors of the 
feet are most often involved. In multiple neuritis there is 
usually local sensitiveness lasting a longer time than in poliomye- 
litis ; the paralysis is gradual in its onset, and sensation as well 
as motion is affected. 

Diphtheritic Paralysis. Diphtheria is the most common cause 
of general weakness terminating in paralysis, but in these cases 
there is usually a history of the preceding disease. The paralysis 
appears first in the muscles of the throat and neck, and a general 
and increasing weakness precedes for a considerable interval the 
complete loss of power. 

Weakness. Pseudoparalysis. Weakness caused by rhachitis or 
so-called pseudoparalysis, due to this or to other affections, is 
readily distinguished from actual paralysis by pricking the part 
with a pin, when muscular contraction and movement of the limb 
w T ill be evident. This test of function is of value in showing 
the distribution of the paralysis. Loss of power in the tibialis 
anticus muscle, for example, causes valgus resembling closely the 
ordinary valgus due to simple weakness. In simple weakness 
the child withdraws the foot from the point of the pin, and the 
ability to move it in all directions is very evident ; but if the 
tibialis anticus muscle is paralyzed the foot is always flexed in 
the abducted attitude. The same test may be made for paralysis 
of other muscles or muscular groups. It is a test that is easily 
applied and that is especially useful in the examination of young 
children. 

Obstetrical Paralysis. Paralysis of the arm due to anterior 
poliomyelitis is infrequent as compared with that of the lower 
extremity. This form might be mistaken for obstetrical par- 
alysis, but the history of the disability and its distribution 
should make the diagnosis clear. 

Prognosis. Only in very rare instances does the disease of 
itself cause death. The prognosis as to function depends pri- 
marily upon the area of the destructive disease of the cord, 
secondarily upon the treatment of the weakened or disabled part. 

As has been stated, the extent of the primary paralysis is 
very much greater than that which ultimately remains when the 
inflammatory changes about the diseased area in the cord have 
subsided. 

The Electrical Test. During the early stages of the disease the 
degree of final paralysis may be fairly estimated by the electrical 
reaction. Within a week after the initial paralysis the reaction 



DISEASES OF THE NERVOUS SYSTEM. 589 

to the faradic current in the muscles and nerves in direct con- 
nection with the diseased area is lessened and is soon lost. If 
the faradic irritability is retained in the paralyzed muscles, or if 
ir is merely diminished, recovery may be predicted. The muscles 
which no longer react to the faradic irritation may still be made 
to contract by the galvanic current. In normal muscles the 
reaction is greatest at the closing of the negative pole. In the 
paralyzed muscles the reaction is slower, it requires greater stimu- 
lation, and the contraction is greater at the closing of the positive 
pole. This is known as the reaction of degeneration. The loss 



Fig. 354. 




Anterior poliomyelitis. Extreme flexion deformity at the hips, inducing the 
quadrupedal attitude. (Gibney.) 



of faradic reaction and the change in the galvanic reaction indi- 
that the function of the affected muscle is lost, although cer- 
tain of it- fibres may in time regain their power. 

The Effects of Paralysis of Different Muscles and Groups of 
Muscles upon Function. The interest in anterior poliomyelitis 
lies in ita immediate and ultimate effect upon the functional 
ability of the individual. These effects may be classified as 
deformity of tin part directly involved. Tin general effects of 
weakness, deformity, and loss of growth upon the body as a whole. 



590 ORTHOPEDIC SURGER Y. 

Causes of Deformity. The deformities of anterior poliomyelitis 
are caused : 

1. By the force of gravity. 

2. By the unopposed action of the muscles whose power 
remains. 

3. By functional use. 

All these and other less important causes of deformity are, of 
course, combined in most instances. The relative importance of 
each factor varies, according to the muscular group that is in- 
volved, with the age of the patient, and with the strain to which 
the part is subjected. The influence of the different factors can 
be studied best in the foot. 

Muscular Action and Gravity. In by far the larger number of 
cases, one or more of the anterior muscles of the leg, the dorsal 
flexors of the foot are involved. This is illustrated by the 
statistics of acquired talipes, tabulated elsewhere, the equinus 
type of deformity being three times as common as the calcaneus 
form. 

If the anterior muscles are paralyzed in a child before the 
walking age, the foot drops under the influence of the force of 
gravity into the attitude of equinus. If this attitude is allowed 
to persist, the muscles on the posterior aspect of the limb, accom- 
modating themselves to the habitual attitude, in time become 
structurally shortened. In such cases the equinus deformity is 
caused by the force of gravity ; it is increased by muscular action 
and it is fixed by muscular adaptation. That deformity is not 
caused directly by muscular action is shown by the fact that it 
may be prevented by stimulating the paralyzed muscles from 
time to time with galvanism, or even by systematic passive 
movements to the limit of dorsal flexion. Deformity is thus 
prevented, not by opposing muscular action, but by stretching 
the active muscles to their full limits from time to time, and thus 
preventing muscular adaptation and structural change. In the 
instance cited gravity and muscular activity are combined in the 
production of equinus, but in other instances gravity and mus- 
cular power may be opposed to one another. If, for example, 
the calf muscle is paralyzed while the anterior group retains its 
power, the deformity of calcaneus does not appear until the child 
begins to use the foot, when the peculiar helplessness calls atten- 
tion to the disability, if the diagnosis has not been made before. 
Thus it is that equinus may be present when the child is still in 
arms, while the opposite deformity develops much more slowly. 



DISEASES OF THE NERVOUS SYSTEM. 



591 



Fig. 355 



Habitual Posture. There are other cases in which every ves- 
tige of muscular power is lost and in which the foot dangles. 
In this class there is no functional activity or tonic shortening of 
the muscles ; consequently deformity is slow in making its appear- 
ance ; it is not often extreme, and it becomes fixed only by the 
structural shortening of the 
inactive tissues, the ligaments, 
and fasciae. There are, of 
course, other causes for habit- 
ual posture than the force of 
gravity and muscular action, 
such as. for example, the posi- 
tion of convenience in which 
a weak or disabled part might 
be placed, but such causes of 
deformity may be considered 
as instances of functional use 
or rather of adaptation to local 
weak 

Functional Use as a Cause of 
Deformity. Thus far the force 
of gravity, unbalanced mus- 
cular power, and the struc- 
tural change.- in the tissues 
have been considered in the 
etiology of deformity, as it 
might develop in infancy. 
When, however, the patient 
stands and walk-, existing de- 
formities arc exaggerated and 
distortions are developed and 
confirmed by the weight of 
the body billing on the unbal- 
ano d part, and by the action 

c i i • \. ,, Anterior poliomyelitis. Duration seven years. 

of the mtlSCle8 ID the attempt - itrophyand slight lateral curvature of 

U) Supply the function of those ****&**> l ^"»"i « quarter inches oi shorten- 
1 i • Log. 

that are paralyse cL Thus it is 

the deformity develops far more rapidly when a fair amount 
of muscular power remains than when it ie completely lost 
Tali] 

Subluxation. Aside from the distortions due to the causes thai 
i mentioned, there are others induced -imply by weak- 




592 ORTHOPEDIC SURGER Y. 

ness ; for example, when laxity of ligaments and the failure of 
muscular support permits distortion of a limb and subluxation 
or even displacement at a joint (Figs. 356 and 357). Complete 
displacement is uncommon, and occurs practically only at the 
hip. In such cases there is usually flexion deformity of the 
limb. The femur is suspended by the contracted tissues attached 
to the anterior superior spine. This unyielding band forms a 
fulcrum by means of which force applied at the knee may cause 
sudden displacement of the head of the femur inward or upward 
and backward. 

Deformities of the Upper Extremity. Deformities caused by 
paralysis of the muscles of the shoulder and upper arm are 
usually slight because the part is not subjected to the strain of 
weight bearing, and because the force of gravity is opposed to 
muscular contraction. In these cases the loss of support and the 
tension on the capsule allows a considerable separation of the 
joint surfaces so that the atrophied head of the humerus may be 
displaced forward or backward ; but there is not often fixed 
displacement, and consequently persistent distortion due to this 
cause is unusual. 

Paralysis of the muscles of the forearm and of the hand is fol- 
lowed after a time by deformity of the fingers, caused primarily 
by unopposed muscular action, secondarily by accommodation and 
atrophy. 

Deformities of the Neck. Paralysis of one or more of the 
muscles of the neck may induce a paralytic torticollis. This is, 
however, extremely uncommon. 

Deformities of the Trunk. Paralysis of the muscles of the trunk 
may induce distortion and extreme lateral curvature of the spine. 
This curvature is not usually caused, as might at first appear, 
by contraction of the active muscles and thus a bending of the 
trunk with a convexity toward the weaker side. As a rule, the 
curvature is, as a whole, in the opposite direction. This is 
explained by the fact that if the paralysis is limited to one side 
and is extensive enough to cause distortion of the trunk, the 
muscles of respiration being involved, the chest wall becomes 
inactive and collapses. In compensation the opposite side of 
the thorax increases in volume and lung capacity and the 
weak, atrophied, and sunken side is drawn toward it. The 
same effect is observed when the arm and the shoulder mus- 
cles are paralyzed, the spine bending toward the side that is 
still active. 



DISEASES OF THE NERVOUS SYSTEM. 593 

Paralysis of the posterior group of muscles, if extreme, may 
cause a kyphosis. Paralysis of the muscles of the abdomen may 
induce lordosis, but in this group of cases the lower extremities 
are usually involved, and the secondary distortions due to posture 
and to functional use mask the direct effect of the paralysis of 
the muscles of the trunk. And, again, the overuse of the arm 

Fig. 356. 




a recurvatum. (See Fig 

muscles in patients whose lower extremities are paralyzed, and 
the suspension of the body on crutches in walking, modify the 
ultirn to in those cases iii which the paralysis is wide- 

spread in its area. See Lateral Curvature.) 

Retardation of Growth and Secondary Deformities. The effects 
of anterior poliomyelitis are not Limited to the paralysis and to 



594 



ORTHOPEDIC SURGERY. 



atrophy of the muscles, but all the compoueut tissues of the 
affected limb are involved as well. The bones become relatively 
atrophied, and their growth is retarded to a degree proportionate 
to the extent of the paralysis and to the functional disability that 
has resulted. It has been stated, however, that retardation of 
growth does not always correspond to the amount of paralysis. 
In some instances paralysis of a single muscle, which does not 
seriously compromise the function of the part, is attended with 
greater shortening of the limb than in other cases in which the 
paralysis is far more extensive. Thus it may be inferred that 
certain cells in the spinal cord are especially concerned in the 
growth and nutrition of the bones, and that interference with the 
function of these cells may not correspond absolutely to the extent 
of the destructive process. However this may be, it is certain 

Fig. 357. 




Anterior poliomyelitis. 



Paralysis of muscles at the hip allows subluxation of the femur. 
The same patient as in Fig. 356. 



that atrophy and retardation of growth are much greater when a 
limb is not used than when by the aid of apparatus it has been 
enabled to carry out, in part at least, its proper function. It is 
evident, also, that retardation of growth will be more marked 
during the period of rapid development ; thus, the younger the 
patient the greater should be the ultimate inequality of the limbs. 

Retardation of Growth. The ultimate shortening varies 
from one to three inches. In the slighter degrees of paralysis 
affecting the leg, the shortening may be less than an inch, but 
when the thigh muscles are paralyzed, also, it may be much more 
(Fig. 355). This inequality is usually very evident in the size 
of the two feet. 

When both limbs are paralyzed so that locomotion is very 
seriously interfered with, the retardation of growth is especially 



DISEASES OF THE XERVOUS SYSTEM. 595 

marked, and the contrast between the trunk of the patient and 
the attenuated lower extremities is very striking. 

Secondary deformities must include, besides those already 
mentioned, the compensatory distortions of the trunk that may 
follow paralysis of the limbs. Thus a short leg might cause a 
lateral curvature of the spine, or great flexion contraction of the 
thigh might induce abnormal lordosis. As a matter of fact, the 
final effects of disabilities of this character are very complex, and 
are influenced by many factors of which only a general indication 
is practicable. 

Treatment. The treatment of the acute stage of anterior 
poliomyelitis is symptomatic. If the diagnosis has been made, 
Bach measures a- would tend to relieve the congestion about the 

- sed area should be employed ; cathartics, sedatives, and 
counter-irritation of the spine, for example. When the acute 
symptoms have subsided local treatment to maintain as far as 
possible the nutrition of the muscles, to prevent deformity, and 
to relieve the strain upon the weakened tissues is indicated. The 
nutrition of the parts may be improved by massage, by muscle- 
beating, by the direct application of heat to the cold extremities, 
and by the nse of galvanism, as long as it will induce contraction 
of the paralyzed muscles. 

• rmity may be prevented by moving each joint to the limit 
of the range of motion in all directions several times a day, and 
by supporting the limb with appropriate apparatus. Deformity 
in those parts in which it is favored by muscular action and by 
the force ol gravity appears much more rapidly than is generally 
supposed. The indications of equinus, for example, are apparent 
within a few week- after paralysis of the anterior muscles of the 
The first indication of such deformity in this class is the 
ifort caused by passively moving the foot toward dorsal 
flexion. This Limitation of the range of motion rapidly increases, 
and a- it increases it i- confirmed by muscular adaptation and 
finally by structural shortening. 

The Principles of Mechanical Treatment. The object of a brace 
prevent the deformity dm- to weakness and to utilize the 
muscular power that remains, so that the disabled member may 
carry out it- function. A- each muscle ha- an essential function 
the paralysis "f any one must !><• followed by a certain disability 
and usually by deformity. Muscles vary in importance as they do 
in strength, and the ultimate disability caused by paralysis may be 
predicted very accurately by one who i- familiar with this function. 



596 



OR Til OP ED IC S UR GER Y. 



Paralysis of the Anterior Muscles of the Leg. Par- 
alysis of the anterior leg group causes the so-called steppage gait ; 
the toes drag on the floor when the limb is swung forward, and 
this necessitates an awkward lifting of the knee. The result of 
such paralysis is equinus. Slight equinus has a tendency to 
throw the knee backward, " recurvatum," in order that the 
patient may place the entire sole on the ground. More marked 
equinus obliges the patient to bear the weight entirely on the 
front of the foot, and causes flexion both at the knee and hip. 
If but one of the muscles of the anterior group is paralyzed the 



Fig. 358. 



Fig. 359. 




CT -- 



<?^m 



The Judson brace for paralysis of the quadriceps extensor muscle in connection 
with deformity of the foot. 



tendency to equinus is in so far lessened, but there is an inclina- 
tion to lateral distortion. Paralysis of the anterior muscles causes 
an* awkward gait and often deformity, but the propelling force of 
the limb remains. The indication for support is simple, to pre- 
vent the foot from dropping to the extent that incommodes the 
patient, or practically to hold the foot at a right angle with the 
leg. 

Paralysis of the Posterior Muscles of the Leg. If, 
on the other hand, the calf muscles are paralyzed the resistance 
of the foot is lost and it is simply dorsiflexed when weight is 



DISEASES OF THE SERVO US SYSTEM. 



597 



thrown upon it. Thus the brace must be arranged to prevent 
dorsal flexion, and it must be strong enough to support the strain 
which is transmitted from the foot plate of the brace to the front 
of the le£. The various weaknesses and deformities of the foot 



Fig. 360. 



Fig. 361. 





A brace for complete paralysis of the 
limb, showing a form of lock at the 
knee and a limited joint at the ankle. 



Anterior poliomyelitis. Paralysis of the 

anterior and posterior muscles. Recurva- 
tion of the right knee. 



and the mean8of treating them are described at length elsewhere. 
I 
Paralysis of the <-.i\f muscles no( only affects the foot, but it 
ens the knee as well, and genu recurvatum is often a 



598 ORTHOPEDIC SURGER Y. 

secondary effect. In many instances, therefore, it will be neces- 
sary to support the knee as well as the ankle during the earlier 
stages of the treatment. 

Paralysis of the Thigh Muscles. Paralysis of the quad- 
riceps extensor muscle causes primarily a peculiar gait. The 
patient, unable to extend the leg upon the thigh, throws or 
swings it forward, then locks the joint by direct contact of the 
bones and by the resistance of the posterior tissues, by inclining 
the body somewhat forward as the weight falls upon it. In this 
manner, again, the knee may be overextended. Or if extension 
is checked by shortening of the tissues, induced possibly by 
habitual assumption of the sitting posture, the patient being 
unable to lock the joint effectively by complete contact of the 
bones, often trips and falls because of the insecurity of the sup- 
port. When in the normal subject the weight is borne upon one 
limb in the attitude of rest, in which the muscles are thrown out 
of action, the knee-joint is locked, but the insecurity of this sup- 
port is illustrated by the school-boy's trick of striking the back 
of the knee with the hand, when, the muscles being taken 
unawares, the person falls to the ground. This insecurity is 
constant when the extensor of the leg is paralyzed. 

Paralysis limited to the quadriceps extensor muscle is, how- 
ever, very unusual. In almost all cases some of the leg muscles 
are involved also, and the brace usually must serve to support 
the foot as well as the knee. In its ordinary form such a brace 
is constructed of two lateral upright bars, reaching nearly to the 
pubes on the inner and to the trochanter on the outer side, joined 
to one another by bands passing beneath the thigh and the calf, 
and attached to a light steel foot plate. If the dorsal flexors of 
the foot are paralyzed the ankle-joint is arranged to allow dorsal 
flexion, but to prevent extension beyond the right angle. If the 
calf muscle is paralyzed a reverse catch is used, or the uprights 
are attached directly to the foot plate without a joint (Fig. 359) ; 
or the so-called limit joint, allowing only a few degrees of motion 
in either direction, is used (Fig. 360). (See Talipes.) In the 
treatment of young children the joint is also omitted at the knee, 
the limb being firmly held in the extended position during the 
active period (Figs. 359 and 362). This is of advantage because 
the joint is the weakest part of the brace and it soon becomes loose 
under the severe strain to which it is subjected. In older sub- 
jects a joint is arranged with a spring catch, the brace being held 
in the straight position when the patient is walking about, but 



DISEASES OF THE XEB Vol's SYSTEM. 



599 



allowing flexion when the sitting posture is assumed. This is, 
of course, a great convenience (Fig. 360). In fitting the brace 
the lateral bars should be adjusted to support the limb without 
uncomfortable pressure, and the joints should be exactly opposite 
the normal centres of motion. The thigh and leo; bands should 
be properly fitted to the contour of the soft parts so that half 
the limb is contained within them. These are smoothly covered 
with leather, and the limb is held in position by leather bands 

fig. 362. 




Brace for complete paralysis of the a: idea of the limb ; before and after covering. 



that complete the circumference. Other bands are applied across 
the from or back of the Limb, either t<> support it or t<» fix it 

firmly in place. In tie- ordinary hne-e without the joint ;it the 

knee there are three anterior Land-, one across the front of the 
thigh, another across the leg, and the third, a mde knee-cap, 
supports the greater part of the -train (Fig. 362 . 

Paralysis of the Muscles of the Bip. Tin- effeel of 
paralysis of the muscles about tie- hip Is diffico.il to describe, as 



600 ORTHOPEDIC SURGER Y. 

in these cases many other muscles are usually involved. If all 
the muscles are paralyzed the thigh dangles. This is, however, 
very unusual, for the tensor vaginae femoris almost always 
retains its power and is one of the causes of flexion deformity 
which is so often present in cases of this character. 

Paralysis of the iliopsoas muscle makes it impossible for the 
patient to flex the thigh directly. If the adductors are paralyzed 
he must lift the thigh with the hand when adduction is desired. 
Paralysis of the glutei is made evident by the atrophy and by the 
weakness of the extending power of the limb. 

The distribution of the paralysis of the muscles of the hip may 
be ascertained by placing the patient in the recumbent posture ; 
the leg is then lifted from the table, and by placing the thigh in 
different positions the ability of the patient to move it may be 
tested, in older subjects by voluntary effort, in younger ones by 
pricking the part slightly with a pin. 

General weakness of the muscles of the hip causes an awkward, 
insecure gait, accompanied usually by outward rotation of the 
limb, and, as has been stated, there is almost always accompany- 
ing paralysis of other muscles of the extremity. In such cases a 
pelvic band must be attached to the leg brace. The pelvic band 
is made of sheet steel of about 18 gauge, two inches wide, fitted 
to the pelvis, which it encircles midway between the crest of the 
ilium and the trochanter. At this point it is attached to the brace 
by a free joint (Fig. 363). When the band is accurately adjusted 
and strapped firmly about the pelvis, the necessary security is 
assured and the attitude of the limb in walking can be regulated. 
If greater support is desired a perineal band may be applied as 
described in the chapter on disease of the hip-joint. 

If both limbs are paralyzed double braces must be used. If 
the muscles of the lower part of the back are much weakened 
the pelvic band may be replaced by a corset or some form of 
back brace. Fortunately these cases are uncommon. 

Paralytic Scoliosis. Paralytic scoliosis requires the sup- 
port of corsets or braces as a rule, such as are used in the 
treatment of other forms of distortion of the back. (See Lateral 
Curvature.) 

Paralysis of the Arm. Paralysis of the arm is uncommon, 
and treatment is rarely demanded. 

In some instances a shoulder support may be of service or a 
brace to hold the arm at a right angle if the biceps is paralyzed. 
If the muscles of the scapula retain their power the operation of 



DISEASES OE THE NERVOUS SYSTEM. G01 

arthrodesis might be of service in fixing the dangling joint, and 
the same operation might be useful at the elbow. It is, of course, 
evident that one of the lower extremities, although hopelessly 
weakened, may be braced so that it may serve as a simple prop 
to bear weight, but as the function of the arm is quite different, 
extensive paralysis of its muscles makes it practically useless to 
the individual. 

Operative Treatment. The Reduction of Defobmity. In 
a large proportion of the cases of anterior poliomyelitis the 
patients are not seen by the orthopedic surgeon until months or 
y*ar- have elapsed since the original attack. They are then 
brought for treatment because of secondary deformity often of an 
extreme degree. At least half of the cases of talipes are due to 
this cause, and with the deformity of the foot are often combined 
other distortions varying in decree with the extent of the 
paralysis. Many of the patients hobble about on a distorted foot, 
Others use crutches, and in a smaller number the only method of 
Locomotion i- creeping on all-fours. In the cases in which the 
patient has habitually used crutches allowing the paralyzed limb 
to " dangle/ 5 there is usually marked flexion at the three joints. 
The thigh is flexed upon the pelvis, the leg is flexed upon the 
thigh, and the foot hangs downward and inward (plantar flexed) 
in an attitude of (<jiiino varus. 

However extreme the paralysis of a lower extremity may be, 
the Limb maybe made useful as a prop when properly braced ; 
tlii- prop will enable the patient to dispense with the use of 
crutches and thin free the arms from unnecessary work. Even 
if both limb- are paralyzed they may at least serve as supports to 
• nable the patient to stand erect and to propel himself with the 
aid of crutches. If a limb has been disused for a long time, 
tie atrophy i- usually extreme, the bones are fragile, and the 
growth baa been greatly retarded as compared with those limbs 
in which deformity ha- been prevented and in which the weight 
of the body ha- been sustained in functional use. In this class 
of cases the first step musl be the reduction of deformity; the 
lust be brought to a right angle with the Leg, the limb must 
be brought to tie- straight line, and the flexion at the hip musl !"■ 
>iie- in order to enable the patient to stand erect without 
bending the -pine forward i n compensatory lordosis. 

Acquired deformity of the foot i- far less resistant than i- the 

nital form, and by tenotomy and the proper application of 

it may be readily straightened, usually at one sitting. 



602 ORTHOPEDIC SURQER Y. 

The flexion contraction at the knee may be overcome also by 
careful and persistent manual stretching combined, if necessary, 
with division of the contracted tissues on the posterior aspect of 
the joint. (See page 412.) 

The flexion deformity at the hip is usually fixed by the con- 
traction of the tissues about the anterior superior spine of the 
ilium, including the tensor vaginae femoris muscle, which is rarely 
paralyzed. These tissues, together with the fascia, may be divided 
subcutaneously, or by open incision, if necessary ; after which 
the deformity may be reduced by gradual forcible extension of the 
thigh while the pelvis is fixed by flexing the other limb upon the 
body. When the contraction deformities are overcome lateral 
deviation at the knee is corrected, if it be present, in the same 
manner, and the bony points having been carefully protected by 
padding a long spica plaster bandage is applied to fix the limb. 

The lesser degrees of deformity may be reduced by other 
means, for example, by repeated applications of plaster bandages 
under slight corrective force, or by manipulation, or by braces 
and bandaging. 

Paralytic knock-knee may be corrected by the Thomas knock- 
knee brace, and this brace when attached to a pelvic band is a 
useful form of support in the routine treatment of paralysis of 
the leg (Fig. 339). 

The Thomas caliper knee brace is another cheap and useful 
support. It is of especial service when there is flexion or lateral 
deformity of the limb (Fig. 259). 

When distortion has been overcome and when functional use 
has been made possible by proper support, the development of 
active muscles which have been thrown out of use by the distor- 
tions, and of those in which part of the muscular substance has 
been retained, is surprising. In many of these cases the distor- 
tions which developed during the temporary paralysis have alone 
prevented recovery, and this latent power may be revived even 
after years of disuse. Thus in many instances prognosis is 
impossible until the deformities have been corrected and until the 
limb, properly supported, has been enabled to resume its function. 

Tendon Transplantation. This operation is best adapted 
to the treatment of distortions of the foot caused by paralysis of 
the muscles of the leg, and the procedure is described at length 
in that section. 

Paralysis of the muscles of the arm and hand is unusual. The 
operation of tendon shortening combined with transplantation of 



DISEASES OF THE NERVOUS SYSTEM. 603 

the tendons of one or more active muscles may be of service in 
the treatment of wrist-drop, and opportunities may suggest them- 
selves in other situations whenever it is possible to utilize the 
muscular power to better advantage. 

Arthrodesis. As has been stated of tendon transplantation, 
arthrodesis is of greatest service at the ankle-joint, where it may 

Fig. 363. 



Leg brace, with i-f.vif hfni'i. Donl No Joint at knee. For paralysis 

Of the anterior thigh a -Hes. 

to tix the foot at a right angle with the leg. Bee Talipes.) 
In exceptional cases arthrodesis or excision at the knee may be 
advisable in tli<- older patients, but in young subjects the strain 
upon the long, wreak lever formed by the two bones will almost 
always induce deformity. Arthrodesis at the hip might be of 



604 OBTHOPEDIC SURGERY. 

service in complete paralysis of the pelvic muscles, at the shoulder 
when the muscles attached to the scapula are active, aud in 
exceptional eases at the elbow and wrist to assure an improved 
position. The operation is described elsewhere. 

OSTEOTOMY. In rare instances, particularly in the extreme 
deformities in the adult, osteotomy of the femur at the hip or 
knee may be necessary in order to overcome resistant distortion. 

Recapitulation of Treatment. This consists in support and 
electrical stimulation of the muscles during the period of recov- 
ery, together with a suitable brace to hold the limb in the best 
possible position for usefulness when the final extent of the 
paralysis has become evident. With the support any treatment 
that will improve the nutrition of the part is of service ; massage 
and muscle beating are of especial value. The limb in which 
the circulation is deficient should be protected from the cold by 
proper covering, and its nutrition may be improved by the direct 
application of heat, the hot-air or hot-water bath both being 
useful. Above all else, functional use, which is made possible 
by apparatus, is of the first importance in preserving and stimu- 
lating whatever muscular power remains ; and special gymnastic 
exercises to this end may be employed if practicable. The pre- 
vention of deformity during the growing period is of great 
importance. Every morning and night the joints of the paralyzed 
part should be passively moved to the normal limits in all direc- 
tions in order to prevent the gradual limitation of the range of 
motion which is the first indication of the deformity. Lateral 
deviation of the limb or foot may be prevented by passive 
manipulation and by careful adjustment or modification of the 
support. Braces should be strong, and as simple as may be 
in construction. Elastic bands and springs, applied with the 
design of replacing paralyzed muscles, are of little practical use, 
since they are ineffective in action, difficult to adjust, and easily 
disarranged. The parent, when treatment is begun, must be 
impressed with the fact that a brace must be strong enough 
to serve its purpose even though its weight be objectionable ; 
that its period of usefulness is limited, and that it must be 
replaced when it is outgrown; that the breaking of a brace 
from time to time is unavoidable, and that such accidents, in so 
far as they are evidences of the functional activity of the patient, 
arc favorable indications. 

Careful supervision of the patient, even though the weakness 
is not great, will be necessary during the period of growth. The 



DISEASES OF THE XERVOUS SYSTEM. 605 

contrast between the development and symmetry, the muscular 
power and practical utility of a limb that has received this care 
and supervision, and one that has been neglected, is sufficiently 
striking to impress anyone with the necessity for this tedious 
and apparently never-ending treatment. 

Thus, in this as in other chronic diseases and disabilities, the 
character and the duration of the treatment, its object, and the 
final results that one may expect to attain by it should be 
explained to the parents when the care of the patient is under- 
taken. 



CHAPTER XVIII. 

DISEASES OF THE NERVOUS SYSTEM (Continued). 

Cerebral Paralysis of Childhood— Spastic Paralysis. 

Cerebral paralysis or palsy is in orthopedic practice second 
only in frequency and importance to anterior poliomyelitis. It 
is, however, entirely different in its distribution and in its effects. 
It is a form of disability that is characterized by motor weakness, 
by stiffness and loss of control, rather than by paralysis. It 
affects entire members and it results in atrophy, contractions, and 
deformity. 

It may involve half the body, hemiplegia. 

It may be limited to the lower extremities, paraplegia. 

It may involve both the upper and lower extremities, diplegia. 

In rare instances but one extremity is affected, monoplegia. 

Distribution. In 451 cases of cerebral paralysis analyzed by 
Peterson, 1 332 were of the hemiplegic type, 73 were of the 
diplegic type, and 46 were of the paraplegic type. In 121 cases 
observed at the Hospital for Ruptured and Crippled, 63 were 
paraplegic or diplegic and 58 were hemiplegic. The hemiplegic 
form of paralysis is usually acquired ; the diplegic and paraplegic 
forms are usually congenital. 

Etiology and Pathology. Cerebral paralysis may be divided 
into two classes — the congenital and the acquired. 

Congenital Paralysis. Paralysis of intra-uterine origin may be 
the result of maldevelopment or injury or a secondary effect of 
intercurrent disease of the mother. Paralysis caused by injury 
at birth is usually the result of rupture of bloodvessels of the 
meninges due to prolonged labor or to the pressure of instru- 
ments. 

Acquired Paralysis. Acquired paralysis may be due to hemor- 
rhage, embolism, thrombosis, or to disease. Sachs 2 presents the 
following classification of causes and effects : 

1 American Text-book of Diseases of Children. 

2 Sachs. The Nervous Diseases of Children. 



DISEASES OF THE NERVOUS SYSTEM. 607 

Paralysis of Intra-uterine Origin. 

Large cerebral defects — true porencephaly. 

Hemorrhages of intra-uterine origin — softening. 

Agenesis corticalis. 
Paralysis Occurring during Labor. 

Meningeal hemorrhage — very seldom intracerebral. Result- 
ing conditions : meningo-encephalitis chronica ; sclerosis ; cysts ; 
atrophies ; porencephalies. 

Fig. 364. 




Congenital cerebral diplegia. Idiocy. 

Paralysis Acquired after Birth. 

1. Meningeal hemorrhage — very seldom intracerebral. Em- 
bolism : thrombosis in marantic conditions, and occasionally from 
syphilitic endoarteritis. Results of these vascular lesions : cysta ; 
softening; atrophy ; sclerosis, diffuse and lobar. 

2. ( ftronic meningitis. 
.;. Hydrocephalus. 

\. Primary encephalitis (Strumpell). 



608 



ORTHOPEDIC SCliaERY. 



General Symptoms. Motor. The effect of the lesion of the 
brain and of the secondary changes in the cord is to impair the 
voluntary control of the limbs supplied from the affected area, 
and at the same time the inhibition of the higher centres is 
impaired or lost. Thus, together with the loss of power, there is 
usually a corresponding exaggeration of the reflexes causing a 



Fig. 365. 




Spastic paraplej 



-pa~ti<- rigidity of the limbs. This induces distortion, which 
finally becomes fixed by the adaptive changes in the tissues. As 
tin- centres for the nutrition of the paralyzed parts are not in- 
volved, the muscles do not waste and the circulation is but little 
affected Thus the atrophy as compared with paralysis of spinal 
origin (anterior poliomyelitis) is comparatively slight, and this, 
together with the loss of growth, is due rather to the general 



DISEASES OF THE SERVO US SYSTEM. G09 

effects of the disease and to the loss of function than to the 
direct influence of the nervous lesion. 

Mental. In this form of paralysis the lesion is of the brain, 
and the direct injury of its structure and the interference with its 
development is likely to cause mental impairment. This mental 
impairment is usually more marked in the paraplegic or diplegia 
than in the hemiplegic form, because in the latter but half the 
brain is involved, and because the injury or disease occurs at a 
later period of its development. So, also, the mental development 
is usually less interfered with in the paraplegic than in the 
diplegic type. For, although both hemispheres were originally 
in all probability involved, yet the recovery of power in the 
arms shows that the injury was less extensive than when the 
weakness persists in one or both of the upper extremities. 

It is estimated that in 50 per cent, of the hemiplegic cases the 
patients are feeble-minded, although comparatively few (13 per 
cent.) are idiotic. In the paraplegic and diplegic forms of 
paralysis about 70 per cent, of the patients are feeble-minded, 
and from 40 to 50 per cent, are idiotic. (Sachs.) 

Epilepsy is an accompaniment of about 45 per cent, of all 
forms of cerebral paralysis, and in 20 per cent, of the cases 
athetoid or associated movements in the paralyzed parts persist. 
(Peterson.) 

Congenital Weakness and Paralysis. 

The congenital form of cerebral paralysis is often seen in 
orthopedic clinics, because the effect of the lesion of the brain 
in retarding both the mental and physical development first 
attracts the attention of the mother. Thus, infants are brought 
for examination because they are unable to sit or stand or to talk 
at the usual time. In certain instances the cause of the physical 
weakness is -im pl«- idiocy. In such cases the vacant expression, 
tin- inability of the child to recognize even its mother, the extreme 
weakness, and the absence of the spastic rigidity of the limbs will 
make the <li;iL r nosis clear. 

In another class <>f cases the weakness appears to be caused 
simply by retarded cerebral development. The patient is 
apathetic and weak. In these cases, also, there is no evidence 
of paralysis, and the evident intelligence of the patient distin- 
guishes this type from tin- idiotic class. 

In tie- characteristic form of cerebral paralysis :i- Been in early 
life the child may be idiotic, or simply apathetic, or apparently 

39 



610 



ORTHOPEDIC SURGERY 



Yw,. 866. 



norma] in intelligence, but it is always weak, and in the sitting 

posture the spine is usually bent backward into a long, more or 
I as rigid curve, It makes no effort to stand, and when placed 
in the erect posture it will be noticed that the thighs are usually 
pressed closely against one another and that the feet are extended. 
The limbs are " stiff." There is a peculiar resistance to flexion 

at the extended joints, which slowly 
gives way under steady pressure. 
This is the characteristic spastic 
rigidity (Fig. 364). 

Deformities. These children 
usually begin to stand and to walk 
at about the third year or later with 
an awkward, shuffling gait ; the 
limbs are usually flexed, adducted, 
and rotated inward ; the knees touch 
one another or the legs may be 
crossed, while the feet turn inward 
in a persistent attitude of slight 
equinovarus. The equilibrium is 
very easily disturbed, partly because 
of the deformities and partly be- 
cause of direct lesion of the brain. 
In the majority of the congenital 
cases the paralysis is paraplegic in 
its distribution ; perhaps 15 per cent, 
are of the hemiplegic variety, and in 
a somewhat larger number the par- 
alysis is diplegic in distribution 
(Fig. 364). 

It has been stated that the typical 
deformity of the foot was equino- 
varus, but in older subjects who 
have walked about in the attitude 
of flexion at the hips and knees there 
may be an accommodative distor- 
tion of the foot toward valgus, or even to an extreme degree 
of calcaneovalgus. 

As has been stated, in a certain number of cases the intelli- 
gence is not impaired, bnt more often the patients are distinctly 
feeble-minded. They are very nervous, easily startled, emotional, 
and are often unable to speak distinctly, yet it is interesting to 




Acquired cerebral hemii-leuria. 



DISEASES OF THE NEB VO US S YSTEM. 611 

note that this peculiar emotional excitability often passes for an 
extreme degree of brightness of intellect and quickness of per- 
ception. In fact, parents often remain unconvinced that the 
child is lacking in mental power until it reaches an age when 
comparison with other children makes this conclusion inevitable. 

Acquired Paralysis. 

As in adult life, the common form of acquired cerebral par- 
alysis in childhood is hemiplegia. About two-thirds of all the 
cases occur in the first three years of life ; and in about 20 per 
cent, of these the affection of the brain is a complication of infec- 
tious disease. The onset is usually sudden, and is accompanied 
iu the majority of cases by fever, convulsions, and loss of con- 
sciousness. When the child regains cousciousness the paralysis 
of the arm and leg is at once evident, and in about 20 per cent, 
of the cases the face is paralyzed also. 

Deformities. At first the paralysis is a simple powerlessness, 
but soon the exaggeration of the reflexes is evident. As has 
been stated, there is a loss of voluntary power and an increase of 
the reflexes or " stiffness " of the paralyzed members. They are 
no longer competent to assume the more difficult attitudes and 
functions, and these are replaced by those that are simpler ; thus 
flexion becomes habitual. 

In typical hemiplegia the foot is plantar flexed and adducted. 
The leg is flexed on the thigh and the thigh on the trunk, and 
with the flexion adduction is usually combined. The arm is held 
against the thorax, the forearm is flexed upon the arm in an atti- 
tude midway between pronation and supination. The hand is 
flexed upon the arm and inclined toward the ulnar side and the 
fingers are clasped over the adducted thumb (Fig. 366). 

Disability. The loss of power is not absolute; in most 
instances the patient is able to walk with an exaggerated limp, 
dragging the stiffened and distorted limb, which serves as a prop 
rather than as an active support. So, also, the control of the 
upper extremities is in part retained ; the patient is able to abduct 
the arm, to partly extend the forearm, sometimes to extend the 
fingers and to abduct the thumb, but the power to dorsiflex the 
hand and at the same time to extend the fingers is not usually 
retained in a case of this character. 

Loss of Growth. The growth of the patient as a whole is 
usually retarded to a certain extent by the lesion of the brain. 



612 ORTHOPEDIC SURGEli Y. 

There is in addition a certain decree of inequality in the growth 
of the two halves of the body. This inequality is more marked 
in the upper than in the lower extremity. Shortening to the 
extent of an inch in the lower extremity is not usually exceeded, 
l)ii t the growth of the arm and hand may he very markedly 
checked. This disproportionate loss of growth in the upper over 
the lower extremity, although it may be explained in part by 
the situation of the lesion of the brain, depends more directly 
upon the interference with function. The lower extremity is 
rarely disabled to an extent that prevents its use in locomotion, 
consequently its nutrition is preserved; whereas the same degree 
of paralysis of the arm utterly unfits it for its more difficult func- 
tions and it becomes a useless appendage. With the disuse of 
function there is a corresponding diminution of nutrition and a 
consequent atrophy and loss of growth. 

Extreme deformity and disability, as in the type described, is 
rather unusual. In many instances there is almost complete 
recovery from the paralysis, only an awkwardness and slowness 
of movement, combined with an increase of reflexes and a slight 
hemiatrophy of the body exists. In some cases a slight degree 
of equinus is the only deformity ; in others weakness of the arm 
may persist, although complete control of the lower extremities 
has been regained. 

The final effect of the paralysis is almost always more marked 
in the upper than in the lower extremity ; thus, when contrac- 
tions and deformities of the lower extremity are present the arm 
and hand are often practically disabled. 

Treatment. 1. Hemiplegia. The treatment from the ortho- 
pedic standpoint consists in stimulating the nutrition of the 
paralyzed parts, in preventing deformity, and in improving the 
functional ability. The results of treatment are, of course, very 
greatly influenced by the mental condition of the patient. If 
the mental power is not impaired one may count upon the efforts 
of the patient to aid the surgeon ; whereas, if the patient is idiotic 
there is but little encouragement for active treatment. If the 
patient is seen before the secondary contractions have appeared, 
deformity may be prevented in great degree by regular massage 
and by passive movements in the directions opposed to the habitual 
positions. Tf the spastic contraction is slight the control of the 
movements of the leg may be made easier by the use of a light 
jointed leg brace attached to a pelvic band. By this means the 
movements are controlled and the excessive expenditure of 



DISEASES OF THE XERVOUS SYSTEM. 613 

nervous energy necessary to guide the limb may be lessened. 
This support should be supplemented by massage and exercise, 
and in the milder type of paralysis the control of the limb may 
be greatly improved. 

In many instances the patients are not seen until late child- 
hood, when the deformities have become fixed. The foot is 
usually turned inward and downward (equino varus) ; there is 
flexion at the knee and often flexion and adduction at the hip, 
the resistance of the contractions being dependent upon the dura- 
tion of the deformity. In such cases the distortions must be 
corrected by force and by division of more resistant tissues, 
including often the tendo Achillis, the plantar fascia, and in 
many instances the hamstrings and the adductors of the hip. 
The limb is then fixed in a plaster-of-Paris bandage for a suffi- 
cient time to overcome the more direct tendency to deformity. 
"When the bandage is removed a brace is of service in guiding 
the limb, and regular massage and forcible passive movements 
together with proper exercises should be employed whenever 
practicable. In this class of cases the deformities may be over- 
come in most instances, but there is a tendency toward flexion at 
the knee, and stiffness and awkwardness in movement usually 
persist. 

In many of the milder hemiplegic cases the only deformity is 
of the foot. This should be treated by division of the tendo- 
A chillis and by support for a time until the deformity habit has 
disappeared. 

If the arm is but slightly affected proper exercises will greatly 
improve its ability. In the more extreme cases, in which the 
fingers are clasped over one another, treatment is of little avail. 
Tn another class, in which the patient has the power of extend- 
ing the fingers only when the wrist is flexed, the power of dorsi- 
flexion may be restored or improved by transplanting the flexors 
of the carpus on the radial and ulnar border to the extensors, 
which have been overlapped and shortened to the proper extent. 
These tendons may be exposed by lateral incisions, and may be 
attached to the dorsal tendons by passing them about the border 
of the radius and of the ulna, or the tendons may be elongated 
by -ilk', which may be inserted directly to the median Burface of 
ltbus or metatarsus. In such instances one hopes thai 
fibrous tissue will be deposited about the artificial tendon and 
finally replace it. In other instances the two tendons have been 
pushed through an opening in the interosseous membrane to the 



614 



OR THOPEDIC SURGER Y. 



dorsal surface of the Avrist, and there united with the tendons of 
the extensors of the fingers. The results of these operations as 
far as improving the attitude is concerned are usually good. The 
transplantation of other tendons may be of service, but the opera- 
tion is limited in usefulness for the reasons stated. 1 Athetoid move- 
ments of the hand and arm may be relieved somewhat by prolonged 
fixation in a plaster bandage, or by arthrodesis at the wrist-joint. 



Fig. 367. 




Cerebral paraplegia, second stage in treatment, the long replaced by the short spica. This 
patient, at the age of eight years, was unable to stand without assistance. The spastic con- 
tractions and deformities were overcome by tenotomies and by force, and a double long spica 
bandage was applied. This was worn for eight months. It was then replaced by the ban- 
dage shown in the illustration. Six months later this was removed. There is at present 
no deformity, and the child walks fairly well. 

2. Paraplegia. The treatment of spastic paraplegia is much 
more difficult than that of hemiplegia, because the disability is 
very much greater, and because the mental impairment is usually 
more marked. 



1 Townsend. Transactions American Orthopedic Association, 1900, vol. xiii. 



DISEASES OF THE NERVOUS SYSTEM. 615 

In general . the treatment in infancy is by massage and bv 
manipulation. When the child shows a. desire to walk an 
attempt should be made to relieve the spastic contractions. In 
certain instances complete correction of all deformities, followed 
by prolonged fixation of each joiut in the overcprrected attitude, 
may be of service (Fig, 367). This may be combined with mul- 
tiple tenotomies if the contractions are more resistant. The 
advantage of tenotomy, aside from the simple correction of de- 
formity, is that by elongation of the tendon the response to the 
exaggerated motor impulses is lessened and an opportunity for 
more effective control is afforded. The beneficial effect of com- 
plete division of contracted parts in checking spasmodic contrac- 
tions is very marked in older patients. Transplantation of 
tendons from the flexor to the extensor aspect of the limb to 
overcome persistent flexion of the knee may be of service in 
certain cases. According to the method of Lange, the tendons 
are exposed by incisions on the lower lateral aspects of the knee. 
They are then carried forward beneath the skin and are attached 
to the insertion of the quadriceps extensor tendon, which is 
exposed by a median incision. The actual insertion is usually 
made by a strong cord of silk prolonged from the extremity of 
each tendon. This is necessary to give it sufficient length. 
The good effect of the operation is to be ascribed in all proba- 
bility in far greater degree to the removal of the deforming force 
than to the extending action of the flexor muscles. Except in 
the very mild cases of paraplegia, and as an aid in retaining the 
limbs in the improved position after operative treatment, braces 
are of little value. The trunk is not, as a rule, deformed 
except in the diplegic cases in which the mental impairment i- 
great. Manipulation, massage, and posture are of some service 
in correcting and preventing this distortion. 

Prognosis. It i- Btated by Peterson 1 that the patients in 
whom the paralysis is paraplegic or diplegic in distribution 
usually die before the twentieth year, and that but few of those 
in whom it i- hemiplegic reach the age of forty. This prog- 
Dosis applies, it may l.c assumed, rather to the extreme cas< - 
>mpanied by mental impairment than to the milder form-. 
In almost all cases the patient, even if idiotic, is finally able to 
Stand and to walk. As a rule, there is for a time a gradual 
improvement in motor power and in mental control as well. It 

1 Transactions American Orthopedic Association, 1900, vol. xiii. 



616 ORTHOPEDIC SURGERY. 

is evident that in a class in which mental enfeeblement is so 
common and in which epilepsy is present in so large a propor- 
tion of cases, moral and mental training is of great importance. 

Orthopedic treatment, although it has no direct action upon 
the lesion in the brain, certainly has an indirect effect upon the 
mental as well as upon the physical condition of the patient. 
When deformity has been corrected and when contractions have 
been overcome, functional use requires less mental effort ; and 
motor control may be still further improved by drilling the patient 
constantly in simple movements. Such exercises improve the 
motor communications and the ability of the paralyzed part as 
well. 

Spastic Spinal Paralysis. 

Occasionally one encounters cases of spastic paraplegia in 
which there is no cerebral impairment. In such cases the lesion 
appears to be confined to the spinal cord and to be a degeneration 
of the distal portions of the pyramidal tracts due to imperfect 
development. 1 The treatment is similar to the ordinary form of 
spastic paraplegia, but the prognosis is far more encouraging. 

Progressive Muscular Atrophy. 

Progressive muscular atrophy, as the term implies, is a pro- 
gressive wasting of the muscles, with corresponding loss of power, 
terminating finally in paralysis and deformity. Its cause is 
apparently some developmental defect. 

Under this title are included two varieties of disease : 

1. The myelopathic form, in which the primary disease is ap- 
parently of the spinal cord. 

2. The myopathic form, in which the disease appears to be 
primarily of the nerve terminals and the muscular fibres. 

The second variety is usually designated as muscular dystrophy 
to distinguish it from the spinal form. 

Myelopathic Paralysis or Atrophy. The myelopathic form 
of muscular atrophy, the Aran-Duchenne type, usually begins in 
the small muscles of the hands and spreads from the periphery 
to the trunk. Fibrillary twitching of the affected and unaffected 
muscles is fairly constant, and the reaction of degeneration may 
be present. The disease is practically limited to adults, and 
from the orthopedic standpoint it is of little interest. In another 
form, the Charcot-Marie-Tooth type, usually classed with the 

1 Spiller. Philadelphia MedicalJournal, June 21, 1902. 



DISEASES OF THE XERVOUS SYSTEM. 



617 



muscular atrophies, the paralysis may begiu iu the muscles of the 
legs, causing deformity of the equinus or equinovarus variety. 
The lesiou of the cord iu muscular atrophy is of the anterior 
coruua, and resembles closely that of the subacute form of 
anterior poliomyelitis. 



Fig. 36$. 



Fro. 369. 





Progressive muscular dystrophy, 
showing the enlargement of the calves 
and the atrophy of the shoulder muscles. 



Progressive muscular dystrophy, f'acio- 
scapulo-humeral type. Extreme lordosis 
and flexion contractious at the hips. 



Myopathic Paralysis or Muscular Dystrophy. The myo- 
pathia form of muscular atrophy may be preceded by apparent 
hypertrophy (pseudohypertrophic muscular paralysis), it may be 
primarily atrophic, or the two forms may be combined. 



618 OR TROPE DIC S UR GER Y. 

It differs from the myelopathic form in several particulars. 
It is a disease of childhood. It is often hereditary and its dis- 
tribution is different. 

The affection is divided according to the distribution into two 
main varieties : 

1. The facio-scapulo-humeral type (Landouzy-Dejerine), in 
which the muscles of the face and shoulder girdle are primarily 
affected (Fig. 369). 

2. The juvenile form of Erb, in which the muscles of the back 
and of the upper arms are first involved. 

The etiology, pathology, and clinical course of the atrophic 
do not differ essentially from the pseudohypertrophic form. 

Pseudohypertrophic Muscular Paralysis. Pseudohyper- 
trophic paralysis is characterized by progressive weakness of the 
muscles of the trunk and of the legs, associated with apparent 
hypertrophy of the calves due in great part to a deposit of fat in 
the wasting muscles (Fig. 368). 

The symptoms are caused by a degenerative atrophy of the 
nerve terminals and of the muscular fibres and an increase of the 
connective tissue and replacement of the muscular substance 
by fat. 

Diagnosis. The interest in this latter affection from the ortho- 
pedic standpoint lies in the diagnosis in the early stage of the 
affection. At this time the patient is evidently weak ; he walks 
with an awkward, shambling gait, and climbing stairs is especially 
difficult. There is usually an increased lordosis and a peculiar 
swaying or waddle, a disinclination to stoop, and an evident 
difficulty in regaining the erect posture, and there may be dis- 
comfort or pain referred to the lumbar region. If the disease 
is advanced, the peculiar hard, resistant enlargement of the calves, 
combined, it may be, with atrophy of the muscular groups of the 
upper extremity, and weakness of the muscles of the back, makes 
the diagnosis evident, but in young children the disease may be 
mistaken for Pott's disease, simple weakness, or postural deformity. 
Although there is a superficial resemblance to the general symp- 
toms of Pott's disease, yet the specific signs of disease of the 
vertebra?, pain, and muscular spasm are absent. 

Weakness, a result of malnutrition or disease, is general in 
character and its cause is usually apparent ; it is, of course, not 
accompanied by local hypertrophy. Retarded cerebral develop- 
ment causes general weakness as far as inability to stand is con- 
cerned, but the cause is in this class also usually apparent. 



DISEASES OF THE XERVOUS SYSTEM. 619 

Postural deformities in childhood always have a cause, and as one 
is not content to treat a deformity without ascertaining its cause, 
this search will bring to light the peculiar symptoms of the disease. 

Treatment. In certain instances the discomfort referred to 
the back, due in part to the lordosis, may be relieved by a light 
spinal support. Massage and muscle-training may enable the 
patient to utilize the remaining power to best advantage. 

In the later stages of the disease there may be secondary 
deformities, most marked in the feet, which may be fixed in the 
equinus or equinovarus attitude. This deformity may be cor- 
rected by tenotomy or otherwise, if the patient has not already 
become so weak that walking or standing is impossible. 

Hereditary Ataxia. Friedreich's Disease. 

Hereditary ataxia is an ataxic paraplegia caused by sclerosis of 
the posterior and lateral columns of the spinal cord. The early 
symptoms are inco-ordination and weakness of the legs ; later 
similar symptoms appear in the upper extremities and speech is 
affected. In well-marked cases there is usually distortion of the 
feet toward equinus or equinovarus, and occasionally a posterior 
or lateral curvature of the spine. In one case recently under 
treatment at the Hospital for Ruptured and Crippled, the recti- 
fication of the deformity of the feet was at least of temporary 
benefit. 

Neuritis. 

Localized neuritis after contagious disease or from other causes 
may result in temporary weakness or paralysis of the dorsal 
flexors of the foot, cause toe-drop, and, finally, deformity. In 
such cases the foot should be supported by a brace in normal 
position. This not only prevents deformity, but it hastens the 
run- by preventing tension upon and structural lengthening of 
the weakened muscles. The same treatment may be applied for 
wrist-drop from metallic poisoning. The hand should be sup- 
ported by a suitable brace in the attitude of dorsiflexion until 
the muscles have recovered their power. Obstetrical paralysis 
has been considered under affections of the shoulder. 

Hysterical Joint Affections and Deformities. Functional 
Affections of the Joints. 

8 -■ sailed hysterical and functional affections may be divided 

into tWO groups : 



820 ORTHOPEDIC SURGER Y. 

1. Those in which there is no actual disease or weakness. 

2. Those in which the symptoms of disease or injury, or of 
their effects, are exaggerated or prolonged. 

The first class of cases is small, the second is large. 

Simulation, whether voluntary or involuntary, of organic dis- 
ease can deceive only those who are not familiar with the char- 
acteristics of the disability that is simulated. Every disease has 
certain well-defined symptoms which can no more be imitated by 
a well person than a disabled part can suddenly take on the 
normal appearance and function. 

"Hysterical Hip." 

The hysterical hip is supposed to simulate actual tuberculous 
disease. 

Diagnosis. The symptoms of actual disease of this joint are 
pain, limp, limitation of motion due to reflex muscular spasm, 
muscular atrophy, distortion, and in the later stages the local 
signs of a destructive process ; for example, heat, swelling, abscess 
and displacement of the parts, shortening of the limb, and the 
like. As these later symptoms could not be simulated, they need 
not be considered. 

In actual disease symptoms and effects follow one another 
in regular sequence and correspond closely to the pathological 
conditions that cause them. Pain is not a pronounced symptom ; 
it is more likely to be concealed than exaggerated and it is 
usually referred to the knee. Local sensitiveness is not marked, 
and it is often absent. Distortion of the limb when it occurs in 
the early stage, before the destructive changes are advanced, is 
caused by involuntary muscular contraction, and whenever this 
distortion is great the reflex muscular spasm, which involves every 
muscle about the joint, is also great ; so that the range of motion 
in the joint is small, and it may be absolutely restricted. With 
the distortion there is always a corresponding atrophy of the 
muscles of the limb. If pain is present it is usually worse at 
night than during the day. 

The hysterical simulation of hip disease is characterized by an 
i xaggeration of the symptoms and by absence of the physical 
signs of disease. There is usually an exaggerated limp, great 
distortion, marked local sensitiveness and pain, but absence of 
muscular spasm, atrophy, or other signs of disease. 

The age of the patient, the history of the supposed disease, and 






DISEASES OF THE NERVOUS SYSTEM. 621 

the other evidences of hysteria that are usually present will con- 
firm the diagnosis. 

The same principle applies, of course, to the differential diag- 
nosis of simulated disease at other joints. The knee and the hip 
are those that are most often involved. 

Hysterical Deformities. 

" Hysterical Club-foot." Local deformity distinct from simu- 
lated joint disease is sometimes seen. Several cases of this 
character in which the foot was distorted have been under treat- 
ment at the Hospital for Ruptured and Crippled recently. The 
differential diagnosis is simple. 

Talipes is either congenital or acquired. Congenital talipes 
and all the acquired varieties, other than those of paralytic origin, 
may be at once excluded from consideration. Paralytic talipes 
in the vast majority of cases begins in early childhood, when it is 
either caused by anterior poliomyelitis or of cerebral hemiplegia 
or paraplegia. When these are excluded the remaining causes 
of deformity are very limited. Every variety of nervous disease 
has well-defined symptoms. If actual paralysis is present the 
muscles atrophy and the electrical reactions are changed. In 
hysterical contractions the muscles do not atrophy, and the elec- 
trical reactions are unchanged. 

" Hysterical Scoliosis." A case was recently under observa- 
tion at the Hospital for Ruptured and Crippled in which distortion 
of the trunk persisted for more than a year, and until a suit for 
damages was finally decided. In this case there was a most 
exa Liberated lateral twist of the spine, so that the shoulder 
approached the pelvis. The deformity, however, was not fixed, 
but it could be completely reduced when the patient was in the 
recumbent posture. There was no paralysis, no persistent spasm, 
do evidence of disease or injury. The deformity was of a nature 
that could not be explained by any conceivable lesion, and other 
signs of hysteria were present. 

Treatment. The principles of the treatment of pronounced 
hysteria, of which simulated joint disease or deformity arc In it 
unusual manifestations, an; considered at length in medical and 
aeurological work-, and the subject does not call for special 
mention here. It is evident, of course, that an unequivocal 
diagnosis must !><■ the first and essential step toward cure. In 
tlii- class of cases apparatus is not often indicated unless the 



622 nimioPEDIC SURGERY. 

deformity has persisted for so long a time that the disused 
muscles have become incapable of performing their proper 

functions. 

Functional Affections of the Joints. 

" Neurotic Joints." In this class, although there is no abso- 
lute distinction between it and the preceding variety, there is 
usually a physical basis for the symptoms, however much they 
may be exaggerated. 

The patients are not usually hysterical ; in fact, hysteria in 
the ordinarily accepted sense is uncommon, and although the 
larger proportion of patients are women, yet men and children 
are by no means exempt from the so-called functional affections. 

It must be borne in mind, also, that many of these cases are 
classed as neurotic simply because the cause of the symptoms is 
not apparent. It is only within a few years that the slighter 
degrees of weak foot and its effects have been recognized, and it 
is probable that such cases, together with anterior metatarsalgia, 
the painful fascia of the contracted foot, achillodynia, and the 
like might be considered as neurotic by one unfamiliar with their 
symptoms. It may be inferred that as diagnosis becomes more 
accurate the more restricted will become the class of cases of 
purely imaginary disability, in so far at least as the locomotive 
apparatus is concerned. 

A " neurotic joint " is often caused by injury. A sprain of 
the ankle, for example, may have been treated by prolonged 
immobilization, either because the patient had originally impressed 
the physician with the severity of the symptoms or because of 
persistent discomfort. When the dressing is removed there may 
be congestion and discoloration due to impaired circulation, weak- 
ness and atrophy of the muscles due simply to disuse, and a 
certain degree of infiltration and stiffness caused by the original 
injury. In cases of this character the disability may be pro- 
longed because the patient or the physician mistakes the effects 
of disuse for the symptoms of serious injury or disease. When 
the diagnosis has been made treatment should be directed to 
increasing the activity of the circulation and thus the nutrition 
of the part, by counter-irritation, by massage, by passive move- 
ments, by voluntary exercises and the like, but cure can only be 
completed by restoring functional use. If, therefore, the disa- 
bility is of long standing a temporary brace will be required 
to protect the part from injury, and to increase the patient's 



DISEASES OF THE NERVOUS SYSTEM. 623 

confidence. In milder cases it is possible that without sup- 
port or treatment, other than an assurance of the absence of 
serious weakness, cure may be accomplished, but this is certainly 
unusual. 

What has been said of exaggerated disability at the ankle fol- 
lowing traumatism applies to the treatment of similar affections 
elsewhere. The knee-joint is very often the seat of so-called 
neurosis. Injury at this point in nervous children is often fol- 
lowed by a persistent flexion contraction that may continue for 
weeks after all signs of the injury have disappeared. When the 
attempt is made to straighten the knee the patient screams with 
pain and the muscular resistance is very great. In such cases 
the immediate rectification of deformity and the application of a 
plaster bandage to hold the limb in the corrected position is 
indicated. It must be borne in mind that the persistent assump- 
tion of a deformed position for weeks or months must be followed 
by certain structural changes in the contracted muscles and weak- 
ness in the opposing groups. Thus some assistance may be 
required in the treatment even of the purely hysterical deformities 
because of this weakness. 

In all forms of traumatic neurosis, so called, the possibility of 
a physical basis for the symptoms should be considered, the 
location of the pain or discomfort, and its connection with cer- 
tain movements or attitudes should be investigated. If such 
discomfort is induced or is aggravated always by a certain motion 
or attitude it is reasonable to infer that this has a well-defined 
cause, especially as the pain of a neurotic affection is not often of 
this definite character. In this class of cases limitation of move- 
ment for a time to the painless range of motion by some form of 
support may be indicated. 

Thus far injury has been considered as the starting point of 
the symptoms, but in many cases there is no history of injury. 
In this class the symptoms may have been induced by rheu- 
matism or gout or rheumatoid arthritis, or by neuritis, and such 
possible causes should be investigated and excluded before the 
diagnosis of simple neurosis is made. In neurasthenic patients 
or those who are anaemic, or overworked, the pain and discomfort 
is oft<-n localized in the spine. The "neurotic spine" has been 
considered elsewhere. In the treatment of all cases of this 
group the genera] condition of the patient should receive con- 
sideration, and in connection with the local treatment a change 
of occupation and of scene is often of advantage. 



624 ORTHOPEDIC SURGERY. 

It is hardly accessary to insist again that an accurate diagnosis 
is the first essential of successful treatment. If this is impossible 
at least one may by exclusion of those injuries and disabilities 
and diseases which are evidently not present arrive at a general 
conclusion as to the character of the ailment and shape his treat- 
ment accordingly. 



CHAPTEE XIX. 

CONGENITAL AND ACQUIRED TORTICOLLIS. 

Synonym. Wryneck. 

Torticollis is, as the name implies, a twisted neck, a distortion 
caused in most instances by active contraction or by shortening 
of one or more of the lateral muscles that control the head. 
Similar distortion may be due to disease of the spine, so-called 
false torticollis, but this should be classed as a symptom of the 
underlying disease, not as simple torticollis, of which the distor- 
tion itself is the important disability that demands treatment. 

Torticollis may be divided primarily into two classes : the 
congenital and the acquired. 

( bngemtal torticollis is a painless shortening of the tissues on 
one side of the neck of intra-uterine origin. 

Acquired torticollis is, in most instances, accompanied in its 
early stages by local pain and sensitiveness, and by active con- 
traction of the affected muscles. After a time these acute 
symptoms disappear, leaving simply the deformity. Thus, from 
the therapeutic standpoint, torticollis may be classified as acute 
and chronic, the latter class including the congenital form. 

The sternomastoid is the muscle that is usually involved 
primarily, both in the congenital and acquired forms ; thus, in 
typical torticollis the head is drawn somewhat forward and is 
inclined toward the contracted muscle, while the neck is pushed, 
as it were, away from the contraction (Fig. 370) ; the chin is 
slightly elevated, and turned toward the opposite shoulder — an 
attitude explained by the normal action of the affected muscle. 
[Regular distortions of the head, as posterior or anterior torti- 
collis due to contraction of muscles other than the sternomastoid, 
are, however, not infrequent. These will be mentioned in the 
consideration of the forms of acquired torticollis. 

Statistics. Torticollis is comparatively an uncommon defor- 
mity. In a period of twenty-seven years 507 cases were treated 
at the Hospital for Ruptured and Crippled, as contrasted with 
upward of 5000 cases of congenital and acquired talipes. 

Acquired torticollis is by far the more common variety, as is 

40 



626 



OR THOPEDIC S URGER Y. 



show n by the fact that of the 507 cases but 87 were supposed to 
be of congenita] origin. 

It is often stated that torticollis is more common in males 
than in females, and that the right side is more often affected, 
yet 41) of the 87 congenital cases were in females and the contrac- 
tion was of the left side in 38 of the 58 cases in which the affected 
side was specified. Of the entire number of cases available for 
comparison 24(5 were in females and 198 in males ; in 236 
instances the contraction was on the left and in 196 on the right 
side of the neck. From these statistics it would appear that the 
deformity is somewhat more common in females than in males, 
and that the left side is more often affected than the right. 



Congenital Torticollis. 

In most instances the deformity of congenital torticollis is 
slight at [birth, and it may not attract attention until the child 
sits or walks. Thus it is often difficult to distinguish the con- 

FlG. 370. 




Left torticollis, apparently of congenital origin, showing the secondary distortions 
of head and face. 

genital form from the deformity that may have been acquired 
in infancy, especially as the patient may not be brought for treat- 
ment until the distortion has persisted for many years. 



COXGEXITAL AM) ACQUIRED TORTICOLLIS. 



62' 



In early infancy slight torticollis may be demonstrated by 
fixing the shoulder on the affected side and drawing the head 
forcibly in the opposite direction, when the shortened muscle 
becomes prominent beneath the skin, evidently restricting the 
range of motion. In most instances the sternal division of the 
muscle appears to be more shortened than the clavicular portion. 

In exceptional cases the deformity even in infancy may be 
extreme, and it may be accompanied by well-marked asymmetry 
of the face and even bv distortion of the skull. In this class 



Fig. 371. 




Right torticollis, showing the displacement of the head toward the opposite side. 



the shortening may involve all the lateral tissues, both anterior 
and posterior. Blight asymmetry may be present at birth 
and becomes more marked with the growth. Even in the 
acquired form it appears usually soon after the onset of the de- 
formity, becoming more marked with its continuance. Its cause 
i- the constrained attitude, the restriction of normal use, and 
quently of th<- blood supply, combined with the tension 
upon the tissues of the face, as is evidenced by the fact that it 
becomes 1"— aoticeable after the deformity has been corrected. 



628 orthopedic srncERY. 

In the well-marked cases of long standing, whether congenital 
or acquired, the face is shorter and flatter, the nose and the corner 
of the month and the eyelids even on the affected side are drawn 
downward, and the skull shows evidence of atrophy and de- 
formity. 

Secondary distortions also appear in the trunk in chronic cases. 
These are rotation of the spine to compensate for the lateral dis- 
tortion of the head and an increase in the dorsal kyphosis, " round 
shoulders/' Among the minor secondary deformities upward 
bowing of the clavicle caused by the tension of the contracted 
muscle may be mentioned (Fig. 370). 

In the early stage of torticollis the head is tilted toward the 
contracted tissues, but when the deformity is of longer standing 
the head following the compensatory convexity of the cervical 
spine appears to be displaced toward the opposite shoulder and 
the inclination may be less marked (Fig. 371). 

The compensatory deformities that have been indicated are 
slight in infancy, but they become more marked in later child- 
hood, for in many instances the shortened muscle ceases to grow ; 
thus, an original shortening of half an inch, as compared to its 
fellow, may be increased to two or more inches in later years. 
This fact emphasizes the importance of treatment as soon as may 
be possible after the distortion is discovered. 

As has been stated, the important contraction is usually of the 
sternomastoid muscle, but if the deformity is uncorrected all the 
lateral tissues become shortened, so that at a later stage complete 
division of the cervical fascia as well as of the muscles may be 
necessary before the deformity can be corrected. 

Typical wryneck caused by shortening of the sternomastoid 
muscle is by far the most common form of congenital torticollis, 
but occasionally cases are seen in which the head is but slightly 
inclined to one side and in which the shortening appears to 
involve the lateral tissues in general rather than a particular 
muscle. In rare instances, although the deformity resembles 
that of typical torticollis, the greatest shortening will be found to 
be of the posterior muscles on one side, particularly of the 
trapezius and the levator anguli scapulae. Thus the scapular 
may be elevated and tilted forward. This form of torticollis 
appears to be one variety of congenital elevation of the scapula. 
(See page 229.) Torticollis due to defective development of the 
upper extremity of the spine is a rare deformity that does not 
require special description. 



COXGEXITAL AND ACQUIRED TORTICOLLIS. 629 

Etiology. It may be assumed, disregarding the possible 
influence of hereditary predisposition, that congenital torticollis 
is, in most instances, caused by a constrained or fixed position 
in the uterus for a longer or shorter time before birth. It is, in 
fact, a simple distortion ; and that it has, in the majority of 
cases, no deeper significance is proved by the fact that it may be 
easily and completely cured by simple division or elongation of 
the contracted tissues. 

It would seem that a deformity to be properly congenital must 
be present at birth, yet the theory, first advanced by Stromeyer, 
that congenital torticollis is usually the result of injury at birth, 
has been so generally accepted that it merits further consideration. 

Haematoma of the Sternomastoid Muscle. Haematoma is con- 
sidered to be, and undoubtedly is, evidence of injury. During 
difficult delivery fibres of the muscle are ruptured, usually in 
the upper or middle third of the anterior border, hemorrhage 
follows, which in turn is surrounded by an encapsulating area of 
inflammatory material. This forms a firm, cylindrical tumor in 
the substance of the muscle, which becomes noticeable about two 
weeks after birth, or at least this is the time when it is usually 
discovered by the mother. As a rule, the tumor is not sensitive 
to pressure ; it may or may not be accompanied by restriction of 
motion in the direction causing tension on the muscle. The 
tumor remains for from three to six months, when it usually 
disappears, leaving no trace of its presence. 

The theory of Stromeyer, which until recently was generally 
accepted, is that congenital torticollis is usually caused by rupture 
of the muscle and by myositis about the haematoma. This inflam- 
mation may involve and ultimately destroy a large part of the 
substance of the muscle, replacing it with fibrous tissue, which, 
contracting, causes deformity. 

This Theory is extremely improbable for the following reasons: 

1. Rupture of muscle elsewhere is practically never followed 
by myositis and contraction. 

2. ir has been demonstrated by Heller 1 that it is impossible 
to cause myositis and contraction by any form of injury to the 
muscles of animal- unless it be combined with actual infection 
with pyogenic germs. 

Most of the cases of congenital torticollis seen soon after 
birth present no evidence of haematoma or injury, viz. : In 7 of 

1 Heller. Deutsche Zeits. f. Chir., Bd. xlix. II. 2 and ?,, B. 284. 



630 ORTHOPEDIC SURGERY. 

55 cases of supposed congenital torticollis, investigated by the 
writer, there was a history of injury at birth. In 48 cases no 
mention was made of injury. In the 7 cases referred to the 
deformity was accompanied by hematoma or there was a history 
of a swelling, apparently of this nature ; but in 2 of these the 
hsematoma was coincident with intra-uterine shortening of the 
muscle. 

4. Cases of hsematoma of the sternomastoid muscle are not, as 
a rule, followed by torticollis. Seven consecutive cases of 
hsematoma were examined by the writer with special reference 
to this point. In all the evidence of violence in delivery was 
clear. Two were delivered by forceps, 3 were breech presenta- 
tions, and in 2 version was performed. In 1 case an arm was 
broken and in another paralysis resulted from injury to the 
brachial plexus. Six of the children lived until the swelling had 
nearly or entirely disappeared, and in none did torticollis accom- 
pany or follow the hsematoma. 

5. In certain cases a congenitally shortened muscle may be 
ruptured at delivery ; thus the haematoma is simply a complica- 
tion of torticollis, not its cause. Bruns 1 has reported such a 
case, and two others have been observed by the writer, in one of 
which club-foot was present also. 

6. Hard tumors of the sternomastoid muscle are not always 
the result of injury ; myositis may be of syphilitic origin appar- 
ently occurring in intra-uterine life. In other instances tumors 
of fibrous or sarcomatous nature have been removed from the 
substance of the muscle. Sixteen cases in which cartilaginous 
nodules, apparently of congenital origin, were found in the 
muscle have been reported. 2 

Congenital torticollis in the majority of cases is of intra-uterine 
origin. If it follows injury at birth it is probably an indirect 
result of local pain, discomfort, and irritation of the nerves or of 
an actual infectious inflammation of the injured part rather than 
an effect of the absorption of effused blood. 

Pathology. In the ordinary type of congenital torticollis, as 
demonstrated at operations on children, the substance of the 
affected muscle or muscles is simply lessened in amount, and 
there is a disproportionate area of tendinous substance as compared 
to the contractile tissue. In other instances the muscle may be 
almost entirely replaced by fibrous tissue, or it may be traversed 

i Cent. f. Chir., 1891, No. 26. * Leugemann Beitr. z. klin. Cbir., Bd. xxx. H. 1. 



CONGENITAL AND ACQUIRED TORTICOLLIS. 631 

by fibrous bands, or patches of scar-like tissue may be distributed 
throughout its substance. These degenerative changes, consid- 
ered to be evidences of pre-existing myositis, are probably more 
common among the acquired than the congenital form, and, as a 
rule, they are fouud only in cases of long standing. Secondarily 
all the lateral tissues of the neck are shortened to correspond to 
the habitual attitude, and the compensatory curvatures of the 
spine in time become fixed, so that torticollis may be classed as 
one of the causes of scoliosis. 

Acquired Torticollis. 

Acquired torticollis is an affection of early life, at least 80 per 
cent, of the cases beginning in the first ten years of life. 

As has been stated, congenital torticollis is usually a painless 
shortening of the muscles, while acquired torticollis is, as a rule, 
a painful affection secondary to injury or disease of some of the 
structures of the neck, which causes peripheral irritation of the 
nerves and active contraction of the neighboring muscles. Thus, 
a- a rule, the number of muscles involved in the deformity is 
greater than in the congenital form ; for example, in the ordinary 
form of acquired wryneck the trapezius, which receives in part 
the same nerve supply, is usually involved together with the 
stcrnomastoid ; and irregular forms of distortion caused by con- 
traction of other groups are not uncommon. 

Varieties. The varieties of acquired torticollis may be clas- 
sified conveniently as follows : 

1. The simple or mechanical form due to scar contraction fol- 
lowing destruction of the skin or deeper tissues, as from burns 
or disease. 

2. Acutt torticollis caused by direct irritation of the muscle, by 
injury, by inflammatory affections of the surrounding parts, 
combined in most instances with irritation of the peripheral 

. which causes reflex contraction of certain muscles or 
musfiilar groups. 

Spasmodic Torticollis, A form of convulsive spasm, " a 
ler of the cortical centres for rotation of the head." 
(Wall 

L Irregular Forms of Torticollis. Paralytic;, ocular, psychical, 
and the like. 

r I 1 1 * - first class, thai due to scar contraction, needs only to be 
mentioned. 



632 



oirruori-inc sriiaKRY. 



Fig. 372. 



Etiology of Acute Torticollis. The second class is the most 
important form of torticollis, both as to frequency and as to its 
effect in causing permanent distortion. Of this group, one of the 
most common, and at the same time the least important form, is 
the simple stiff neck, supposed to be due to cold or to muscular 
rheumatism. Its onset is, in childhood, sometimes accompanied 
by slight fever and malaise ; the affected muscle is somewhat 
sensitive to pressure and motion or tension causes discomfort. 
The distortion, in great part voluntary and accommodative, is of 
short duration as a rule. Strains and direct injury of the muscles 
of the neck may cause deformity, which usually disappears when 

the local sensitiveness has sub- 
sided. Traumatic hsematomata, 
similar to those caused by in- 
jury at birth, are sometimes ob- 
served in older subjects. These 
usually disappear after a time, 
leaving no trace of their pres- 
ence. 

Another form of torticollis is 
secondary to cellulitis and to in- 
filtration following the breaking 
down of tuberculous cervical 
glands. This may become a 
permanent distortion if the de- 
formity is allowed to persist or 
if the tissues of the neck are 
injured by the suppurative 
process. 

By far the most important 
variety of this class is the acute 
spastic torticollis due to active 
tonic contraction of one or more 
of the muscles of the neck. The exciting cause of the spasm 
appears to be irritation of the peripheral nerves in the naso- 
pharynx or in its neighborhood, and the muscles most often 
affected are those supplied in part by the spinal accessory nerve. 
Thus torticollis of this form may follow tonsillitis, pharyngitis, 
measles, diphtheria, and the like. It may be preceded by 
" toothache " or " earache/ ' or it may be an accompaniment of 
what appears to be the ordinary form of stiff neck, or of enlarged 
or suppurating cervical glands. In this form the torticollis is 




Bilateral contraction of the sternomastoid 
and trapezii muscles. (See Fig. 373.) 



CONGENITAL AND ACQUIRED TORTICOLLIS. 633 

caused directly by tonic contraction of the muscles. Reflex spasm 
of this diameter is, however, often associated with the distortion, 
due primarily to injury of the neck or to some local inflammatory 
process, so that a sharp distinction between the divisions of this 
second class is impossible. Many of the patients are known to 
be of a nervous temperament, and overstudy, anxiety, sudden 
-hook, and the like are considered to be predisposing causes. 

This variety of acquired torticollis completely overshadows in 
importance all other forms, as is indicated by the statistics of 212 
cases treated at the Hospital for Ruptured and Crippled in which 
the cause seemed to be apparent. Of the 212 cases 181 may be 
fairly assigned to this class. 

The apparent exciting causes of cases of acquired torticollis 
treated at the Hospital for Ruptured and Crippled are showu in 
the following table : 

Enlarged cervical glands . . 14 Cold in the neck 5 

Suppurating " " . 41 Rheumatism 18 



Scarlet fever 14 Vaccinia 1 

Diphtheria 7 Fever 6 

Mumps 6 Malaria 5 

Measles 2 Injury to the neck 35 

Sore-throat 8 Rhachitis 3 

Suppurating otitis .... 3 Syphilis 1 

Toothache 6 Cicatricial contraction .... 3 

Cellulitis of the neck ... 2 — 

Furuncle " " ... 1 Total 181 

Torticollis associated with chorea 4 

" epiiepsy 1 

" " cortical irritation 5 

" hysteria 1 

" meningitis 1 

" " " hemiplegia 3 

Spasmodic torticollis 8 



Functional torticollis 



Total 



Symptoms of Acute Torticollis. As a rule, the distortion of 
tin- neck, alight at first, is more noticeable at night than in the 
morning ; it then gradually increases until the deformity becomes 
fixed. In other instances the onset is sudden, sometimes accom- 
panied by fever. 

As has been stated, in most instances several muscles arc more 
- involved in the contraction, particularly the sternomastoid 
and the trapezius, and iii such cases the deformity is more marked 
and persistent than when the sternomastoid is alone affected. 
Lcs* often the contraction is of the posterior group, fi posterior 
torticollis," when tin- head is tilted backward and the chin is 
turned mop' toward the opposite side than in tin- typical lateral 
form. In other cases the contraction appears to affect the -mall 



634 



oimioPEDIC SURGERY. 



muscles that control the small joints at the upper extremity of the 
spine, when the head may be tilted forward with but slight lateral 
inclination, resembling closely, except in the history, the symp- 
tomatic wryneck of Pott's disease. In rare instances the muscles 
on both sides of the neck may be contracted simultaneously 
(Fig. 372). The contracted muscles are usually sensitive to 
manipulation and attempted rectification of the deformity causes 
extreme pain and is resisted by the patient. The child is, as a 
rule, nervous and irritable ; it often complains of neuralgic pain 
about the contracted part which is increased by sudden or 
unguarded movements or strain; thus "getting the patient to 



Fig. 373. 




Bilateral torticollis after treatment. (See Fig. 372.) 



bed " is often a tedious proceeding, because of the difficulty of 
supporting the head comfortably with the pillows. 

In many instances the affection is of short duration ; in others, 
particularly those in which the reflex spasm is aggravated by 
local inflammatory processes, there appears to be but little 
tendency toward recovery. In such cases, after several weeks 
or months, the local pain and sensitiveness may subside, together 
with the active spasm, but the deformity remains, caused by 
adaptive shortening of the muscles and fascia, aggravated in some 
instances by actual myositis. The muscles atrophy and degen- 
erate and present at a later stage the same pathological appear- 
ances that are found in the congenital form. 



COXGEXITAL AXD ACQUIRED TORTICOLLIS. 635 

Diagnosis. Torticollis is most often confounded with Pott's 
disease. This would seem to be hardly possible in cases of the 
simple painless contraction of chronic torticollis. In the acute 
form, however, there may be more difficulty in distinguishing 
between the two. The main points have been mentioned already 
in connection with Pott's disease. In acute torticollis the affec- 
tion is of sudden onset, not preceded by the stiffness and neuralgic 
pain that characterize tuberculous disease. The deformity of 
torticollis is almost always of the regular type — that is, the head 
is tilted toward the contracted muscles while the chin is rotated 
in the opposite direction. The spasm and contraction of the 
affected muscles are apparent, and direct tension upon them is 
painful. If, however, the tension is relaxed by inclining the 
head toward the contraction, movement of the head in other direc- 
tions will be found to be practically unrestricted. 

In Pott's disease the spasm of muscles is general, the deformity 
is not of a regular type, since the chin often points to the side 
toward which the head is inclined. Steady tension with the aim 
of reducing the deformity is not, as a rule, painful ; in fact, it is 
often agreeable to the patient. Finally the limitation of motion 
cannot be lessened by inclining the head toward the muscle that 
seems to be most contracted, for the reflex spasm of Pott's disease 
limits motion in every direction. As a rule, the diagnosis is 
easily made, but in cases complicated by suppuration of the cer- 
vical glands it is sometimes impossible to exclude Pott's disease 
until after the effect of treatment has been observed. 

Disease of the cervical spine, other than tuberculous, is com- 
paratively rare, and resembles in its symptoms Pott's disease 
rather than torticollis. Arthritis of the atloaxoicl articulation 
may be a manifestation of rheumatism ; it may follow infectious 
disease, or it may occur as an isolated infection. It is of sudden 
onset, and it resembles acute spastic torticollis, except that all the 
surrounding muscles are affected rather than a particular group ; 
in fact, but for the history it could not be distinguished from 
tuberculous disease of this region. 

Although the diagnosis of torticollis is simple, it is not always 
easy to determine the muscle or muscles involved in the contraction. 

The effect of unilateral contraction of the different muscles is 

as follow- : 

The sternomastoid inclines the head toward the contraction, 
displaces it toward the opposite shoulder, elevate- the '-Inn, and 
Turn- it away from the contracted muscle. 



ORTHOPEDIC SURGERY. 



The trapezius lias much the same action, but the backward 
inclination and rotation arc more marked. 

The action of the complex us resembles that of the trapezius, 
but the rotation is less. 

The splenius inclines the head backward and toward the con- 
tracted muscle, but docs not turn the chin in the opposite direction. 

The scaleni have the same action, except that the head is 
inclined forward. 

As has been stated, in acute torticollis several muscles are 
often involved, but the spasm is usually greater in one or in one 
group than in another. The seat of greatest contraction may be 
determined by the deformity, by the evident spasm that resists 
reposition, and by the local sensitiveness on palpation. As a 
rule, when the primary contraction is of the posterior group, the 
deformity is more marked than in other forms. Bilateral con- 
traction of the muscles is rare, but it is occasionally seen (Fig. 
372). 

Treatment. The treatment varies according to the cause and 
with the duration of the deformity. Excluding, for the present, 
the rare and irregular forms of wryneck there are, from the 
remedial standpoint, two forms of torticollis : 

1. The chronic form, in which the local pain and sensitiveness 
are absent, but in which there is resistant and permanent defor- 
mity. As has been stated, congenital torticollis is included in this 
class. 

2. The acute form, in which the distortion is of short duration 
and in which permanent contraction may be prevented. 

The Treatment of Chronic Torticollis. By Manipulation. Con- 
genital torticollis, if of moderate degree, can be overcome in early 
infancy by methodical stretching of the contracted parts. One 
person fixes the arm and another draws the head gently but firmly 
in the direction opposed to the contraction, over and over again, 
meanwhile massaging the tissues of the neck. The procedure 
should be repeated several times a day; it causes slight mo- 
mentary discomfort if properly performed, but this ceases when 
the stretching is discontinued. Care should be taken also that 
the posture may, as far as possible, favor the reduction of the 
deformity ; thus while the child is in the mother's arms the head 
should be supported, and when asleep the pillow may be arranged 
in a manner to prevent the improper position. In this way the 
torticollis may be entirely corrected or its progress may be checked 
until more effective treatment is indicated. 



COXGEXITAL AND ACQUIRED TORTICOLLIS. 637 

Haematoma. The evidence of injury at birth should be treated 
by massage with some bland ointment ; if it is accompanied by 
deformity the manipulation already described should be employed. 

In the great majority of cases of congenital torticollis the 
patient is not brought for treatment until the deformity has 
become an eyesore to the parents. The contracted muscle is then 
usually au inch shorter than its fellow, the disparity increasing, 
as a rule, with the growth of the child. In such cases the imme- 
diate correction of the deformity is indicated, and this implies in 
most instances, division of the contracted parts by subcutaneous 
tenotomy or by open incision. 

By Subcutaneous Tenotomy. If the deformity is comparatively 
slight and if the contraction seems to be limited to the sterno- 
mastoid, and particularly to its sternal portion, one may hope to 
overcome the most resistant part of the contraction by the sub- 
cutaneous operation. Aside from the possibility of wound infec- 
tion, which at the present time is an argument of very little 
weight, subcutaneous tenotomy has the advantages of simplicity, 
apparent freedom from the danger which parents associate with 
an operation, and it leaves no scar behind. It is inadequate, 
however, for the correction of advanced cases. 

The patient and the instruments having been prepared as for an 
ordinary operation, a sand-bag is placed beneath the shoulders and 
the head is inclined so that the contracted muscle is thrown into 
relief beneath the skin. The sternal insertion of the tendon is 
seized with two fingers and the tenotome is inserted beside it and 
passed beneath it at a point about an inch above the sternum. 
It is then divided by a sawing motion of the knife. Division of 
rlii— part of the muscle in this situation is practically free from 
danger, and in the slighter degrees of deformity one can by 
vigorous manipulation and forcible traction overcome the resist- 
ance offered by the other tissues. If bands of fascia resist the 
correction, they may be divided by superficial nicking with the 
tenotome in the lateral region of the neck. As a rule, however, 
in <-a-es of this type the open incision is to be preferred, as it 
allows the opportunity for free division of the contracted parts 
with Less danger of injury to the bloodvessels and nerves in this 
neighborhood. 

By the Open Method. The incision should be made in the line 
of the muscle midway between the sternal and clavicular inser- 
tion. In the milder cases in childhood it need be little more 
than an inch in length. A director may be passed beneath the 



638 



ORTHOPEDIC SURGERY. 



tendon, and on this it may be divided. The clavicular insertion 
and the non-resistant bands of fascia may be divided as they 
appear. 

In cases of very great deformity in the adult some of the pos- 
terior as well as the lateral muscles are involved. In such 
instances the contracted parts may be divided at the upper border 
of the neck through an incision from the mastoid process back- 
ward along the lower border of the scalp, the scar being concealed 
by the hair. 

Overcorrection of the Deformity. The object of treatment is 
not only to straighten the head, but also to overcome all restric- 

FlG. 374. 




Torticollis, left, showing the method of fixing the head in the overcorrected 
position. After operation. 



tion of motion that may remain after the division of the more 
resistant parts, and the operation, whether open or subcutaneous, 
must be supplemented by a vigorous kneading of the lateral 
tissues with the ulnar border of the hand while traction is made 
upon the arm and head. Finally, the head is rotated away from 



COXGEXITAL AXD ACQUIRED TORTICOLLIS. 639 

the contracted parts, the aim being to completely overcome the 
secondary curvature of the cervical spine. 

It may be stated that Lorenz considers it possible to correct 
torticollis, even of long standing, by this system of systematic 
kneading and stretching without previous division of the con- 
tracted tissues, but the use of so much force appears to be unde- 
sirable if by so slight an operation it may be avoided. 

Xot only should all resistance be overcome by vigorous 
manipulation at the time of operation, but the head should be 
fixed during the process of repair in the overcorrected position. 
Thus in the treatment of typical torticollis the chin should be 
turned to a point over the middle of the clavicle on the operated 
side, and the head should be inclined toward the opposite shoulder. 
In this attitude a plaster bandage should be applied surrounding 
the head and the thorax. This bandage should remain until all 
local sensitiveness has disappeared, and until the tendency toward 
deformity has been checked. This fixation in the overcorrected 
position is very important in childhood, as an aid in overcoming 
the deformity habit, but it may be dispensed with in the treatment 
of adults (Fig. 374). 

The plaster bandage is retained from four to eight weeks. 
When it is removed massage, manipulation, and gymnastic train- 
ing are indicated. Twice a day the head should be forced to 
the extreme limit of overcorrection. Traction on the neck in 
self -suspension by means of the sling used in the application of 
the plaster jacket, a regular system of exercises for the muscles 
of the neck and back, and supervision of the habitual postures will 
usually assure a complete cure. If, however, the deformity habit 
is strong so that the head has a marked tendency to resume the 
former attitude, some support is indicated. A simple and effec- 
tive support is the jury mast as used in the treatment of Pott's 
disease with the plaster jacket or attached to a brace. In the 
treatment of children a band of elastic tape arranged to draw the 
head toward the shoulder as suggested by Sayre, or a Thomas 
collar, may be sufficient. 

Ab has been stated, the necessity for support, provided the 
deformity has been thoroughly overcorrected, depends upon the 
care that is to be exercised in the after-treatment. When exer- 
cises and massage can be efficiently employed, the support is not 

-■■ntial. In other cases it may be worn for several months with 
advantag 

The principles of the treatment of the chronic or painless form 



640 ORTHOPEDIC SURGERY. 

of torticollis that have been outlined apply to the acquired as 
well as to the congenital form, when adaptive shortening has 
replaced active contraction. Acquired torticollis is, in most 
instances, however, a preventable deformity ; thus operative 
treatment would be rarely required had the patient received 
proper treatment. 

The Treatment of Acute Torticollis. The insignificant form of 
torticollis called stiff neck may be treated by hot applications ; a 
firm, thick collar of flexible cotton stiffened by several layers of 
adhesive plaster is an agreeable support in the more painful cases. 

In true acute spastic torticollis the cramp-like contraction of 
the muscles is secondary to irritation elsewhere. This one 
should always try to remove, and, as has been stated, the general 
condition of the patient may require treatment as well. But the 
important indication is to support the head in order to relieve 
the pain and to correct the distortion. In the early stage the 
support of the collar that has been described may be sufficient, 
but, as a rule, patients of this class are not seen until the distor- 
tion has persisted for weeks or months even, so that a more 
efficient form of support is required — such is the plaster jacket 
and jury mast. The elastic tension of this appliance overcomes 
the spasm and relieves the discomfort and apprehension which 
have lowered the vitality of the patient (Fig. 53). If the 
spasm is the result of the irritation of enlarged or suppurating 
cervical glands, as is often the case, the rest afforded by the brace 
is an effective treatment of the cause as well as of its effect, and 
if suppuration is present this support is most convenient for the 
dressing that may be required. When the acute symptoms and 
deformity have been relieved manipulation and exercises may be 
employed in the manner already described. 

In cases of longer standing, particularly when the posterior 
muscles are involved, the deformity may be forcibly corrected 
under anaesthesia, and the head may then be fixed in a plaster 
dressing in the manner already described. This treatment may 
be employed at an earlier stage in selected cases. As a rule, 
when deformity has been allowed to persist for six months or 
more, its rectification will require division of the more resistant 
tissues. 

Spasmodic Torticollis. 

Spasmodic torticollis, a form of convulsive spasm of the 
muscles of the neck that is somewhat similar in its general char- 



CONGENITAL AND ACQUIRED TORTICOLLIS. 641 

acteristics to writer's cramp, 1 must not be confounded with the 
acute torticollis of childhood, in which tonic spasm of the affected 
muscles, due usually to some well-defined irritation of the 
peripheral nerves, is the characteristic. Spasmodic torticollis is 
an affection of adult life. Of 32 cases collected by Richardson 
and Walton, 2 but 2 were in patients less than twenty years of 
age. The sexes are equally liable to the affection, and the con- 
traction is as frequent on one side as on the other. 

The onset of the affection is usually gradual. The first symp- 
toms are often sensations of stiffness and discomfort in the 
muscles of the neck; a " drawing sensation" and a momentary 
twitchiug or slight contraction which draws the head to one side. 
These symptoms increase slowly until the head is habitually 
inclined in the attitude of torticollis. For a time the patient can 
correct the position voluntarily, or by supporting the head with 
the hand can restrain the twitching of the muscles, but in well- 
established cases the head is persistently inclined to one side and 
the convulsive spasm is uncontrollable. This latter symptom is 
the most marked peculiarity of the affection ; at intervals the head 
begins to twitch, and it is finally drawn by the convulsive con- 
traction of the muscles into an attitude of extreme deformity. 
As the muscles most often affected are the sternomastoid and 
trapezius the attitude is usually one of typical torticollis. The 
spasmodic clonic contractions may involve the muscles of the 
face or of the chest even. They are more marked when the 
patient is excited or when sudden movements are necessary. As 
a rule, patients complain of neuralgic pain in the head and neck, 
aggravated by the cramp-like contractions. 

Etiology and Pathology. The etiology is obscure. Many of 
the patients present a neurotic family or personal history, and 
overwork, shock to the nervous system, and the like are cited as 
predisposing causes. The affection has been compared to writer's 
cramp, as in certain instances the spasm appeared to be caused by 
constrained positions of the head necessitated by certain occupa- 
tions, aggravated, it may be, by the strain of defective eyesight. 

The affected muscles may be hypertrophied from constant 
activity, and in the later stages of the affection they are, as a 
rule, permanently shortened. Xo characteristic changes in the 
nerves or in the central nervous system have been recorded. 



i Spasmodic torticollis is defined by Walton as a " disorder of the cortical centres for rota- 
tion of the head." American Journal of the Medical Sciences, March, 1898. 
- American Journal of the Medical Sciences, January, 1895. 

41 



<i4*J ORTHOPEDIC SURGERY. 

Prognosis. There is little tendency toward spontaneous 
recovery. As a rule, the spasm becomes more constant and other 
muscles become involved. 

Treatment. It is perhaps unnecessary to state that the 
genera] condition of the patient and the possible local and 
genera] causes of the spasm should receive consideration. As a 
rule, however, the patient will have exhausted both constitutional 
and local treatment before coming under observation. 

In the mild and early cases the avoidance of predisposing 
causes combined with massage, systematic muscle training, and 
in exceptional instances mechanical support may be of service ; 
but in the chronic, severe, and persistent cases of this class the 
resection of nerves supplying the affected muscles has alone proved 
to be efficient. If the spasm is limited to the sternomastoid and 
trapezius muscles, resection of the spinal accessory nerve may be 
sufficient ; but if other muscles are involved or if the spasm recurs 
after the original operation, the removal of the posterior branches 
of the upper cervical nerves, together with extensive division of 
the contracted muscles upon the same side and sometimes upon 
the opposite side also, may be required. 

Resection of the spinal accessory nerve was first performed by 
Campbell de Morgan, of London, in 1866, and since then the 
operation has been repeated many times by other surgeons with 
temporary or permanent benefit to the patients. According to 
Petit, of 26 patients so treated 13 were cured and 7 were perma- 
nently improved. In 5 others the benefit was but temporary, 
and 1 died from erysipelas following the operation. 1 

The Operation. The spinal accessory nerve passes downward 
and backward from the jugular foramen and enters the anterior 
border of the sternomastoid muscle at a point about oue and a 
half inches below the tip of the mastoid process. At this point 
it should be exposed. Dr. E. Eliot, Jr., from a special study of 
the course and relations of the nerve, suggests the following 
method : 2 

" The incision should be generous, for the nerve is situated at 
a considerable depth, and should extend from the mastoid process 
above downward to one or two inches beyond the angle of the 
jaw. The anterior edge of the sternomastoid should then be 
exposed. In the upper part of the wound the posterior and 
inferior portion of the parotid gland may have to be drawn 

1 L' Union M6dicale, July 9, 1897. n - Annals of Surgery, May, 1895. 



CONGENITAL AND ACQUIRED TORTICOLLIS. 643 

forward, although usually it does not overlap the muscle. When 
this is doue it is comparatively easy to expose by blunt dissection 
the transverse process of the atlas, as it lies directly below the 
mastoid process above, while immediately in front of this bony 
prominence, and running downward and forward from the mas- 
toid process toward the angle of the jaw is the posterior belly of 
the digastric. Behind this lie the main vessels of the neck, with 
the spinal accessory nerve emerging from the jugular foramen, 
and the operator is certain that no harm can be done to these 
structures as long as he remains superficial to the digastric belly, 
which in its turn lies at a considerable depth — in fact, at about 
the level of the transverse process of the atlas. 

"Owen and Petit have drawn attention to the fact that the 
nerve usually enters the mastoid muscle at a point opposite the 
angle of the jaw. I have found, however, in a large majority of 
cases that, on leaving the internal jugular it assumes a definite 
relationship with the transverse process of the atlas. Never 
above it, sometimes directly over it, usually a fraction of an inch 
in front of its most prominent part, the nerve may easily be 
detected in the small amount of connective tissue that envelops 
it. and from this point to its entrance into the belly of the muscle 
it may be isolated with safety, and treated by any suitable pro- 
cedure. If, exceptionally, it should escape detection, the anterior 
border of the muscle should be drawn sharply backward at a 
point opposite the angle of the jaw, the nerve in this way put on 
the stretch, and by blunt dissection in the adipose tissue that 
separates the under surface of the muscle from the sheath of the 
vessels the nerve may be readily exposed. Usually the nerve 
passes from under the posterior belly of the digastric, at a point 
just in front of the transverse process of the atlas, to a point on 
the deep surface of the muscle just behind its anterior margin 
opposite tic angle of the inferior maxilla. It is sometimes accom- 
panied by a small artery and vein, the latter easily visible, the 
former a branch of the occipital. Rarely the nerve lies at a con- 
siderable distance from the transverse process of the atlas ; in one 
as much as half an inch anteriorly. Here the nerve could 
be found at it- entrance into the muscle, the landmark of the 
transverse process having failed to Localize its situation." 

Richardson suggests that if the nerve is not readily found its 
position may be ascertained by drawing the finger-nail tirmly 
across the bottom of the wound, a sharp contraction following 
pressure upon it. The nerve having been isolated a section of an 



.ill 



ORTHOPEDIC SURGERY, 



inch shouUl be removed. Richardson advises in addition vigor- 
ous stretching of both extremities, After division of the nerve 
the spasmodic contraction relaxes and the muscles become flaccid, 
allowing the head to be brought to the normal position, or if the 
deformity has become permanent the contracted parts may be 
divided as in the ordinary form. Fixation of the head is not, as 
a rule, required. The operation should be supplemented by 
massage and by muscle-training. If the spasm has been confined 
to the muscles supplied by the spinal accessory nerve, the treat- 
ment may be permanently successful, but in many instances the 
spasm may recur in other muscles. Of these, the posterior group 
of the opposite side is more often affected, and a similar opera- 
tion for resection of the posterior branches of the upper cervical 
nerves may be indicated. This has been performed with success 
by Smith, of London ; Keen, Richardson, and others. According 
to Smith, 1 the operation should be conducted as follows : An 
incision is carried downward from the occiput about three inches 
in length, parallel to and one inch from the spinous processes. It 
ontinned through the trapezius to the edge of the splenitis. 
The oomplexus is then divided and the posterior branches of the 
nerves are exposed ; those of the three upper nerves which supply 
the posterior rotators are then resected. 

Kcen : operates in a somewhat different manner, by a transverse 
incision two and a half inches in length from the middle line of 
the neck on a level with a point one-half an inch below the level 
of the lobule of the ear. The trapezius is divided transversely, 
afterward the oomplexus, care being taken to spare the great 
occipital nerve. The posterior branch of the second cervical 
nerve is then resected : the suboccipital nerve is then looked for 
in the suboccipital triangle, traced down to the spine, and divided. 
The external trunk of the posterior division of the third occipital 
nerve is then exposed below the great occipital and divided close 
to the bifurcation o\' the nerve trunk ; thus the nerve supply of 
the chief posterior rotators, the splenitis capitis, the rectus capitis, 
posticus major, and the obliquus inferior is removed. 

Th.' paralysis that follows even such extensive operations 
seems t«» inconvenience the patient but slightly, while the relief 
fnun deformity and from the eon-taut spasm i< a more than suffi- 
cient compensation for whatever weakness or disability may result. 

The following are the conclusion- of Richardson and AValton : 3 



1 SpasmtHlie Wrynerk, London. I99L 
ry, January, 1891, 



2 Annals of Surgery, January, 1891. 



COXGEXITAL AND ACQUIRED TORTICOLLIS. 645 

1. Palliative treatment, whether by drugs, apparatus, or elec- 
tricity, will rarely prove successful iu well-established spasmodic 
torticollis. 

2. Massage may prove of value in comparatively recent cases. 

3. Resection affords practically the only rational remedy. 

4. Operation on the spinal accessory nerve may afford relief, 
even if other muscles than the sternocleidomastoid are affected. 
On the other hand, the affection previously limited to the sterno- 
cleidomastoid may spread to other muscles in spite of this 
operation. 

5. Xo fear of disabling paralysis need deter us from recom- 
mendiug operation, as the head can be held erect even after the 
most extensive resection. 

6. The most common combination of spasm is that involving 
the sternomastoid on one side and the posterior rotators on the 
other, the head being held in the position of sternomastoid spasm 
with the addition of retraction through the greater power of the 
posterior rotators. 

7. It seems advisable in most cases to give preference to the 
resection of the spinal accessory as the preliminary procedure. 

In a later communication Richardson and Walton 1 report very 
satisfactory final results on cases treated by resection of nerves 
supplying the muscles that were affected by the spasm on one or 
both Bides, combined with complete division of the muscles as 
well, when permanent contraction was present. 

Kalmus* has reviewed the literature of the subject. In 11 
cases <»f simple stretching of the spinal accessory nerve 3 were 
cured. In 68 cases the nerve was resected ; of these 23 were 
cured and 20 were improved. In 4 there was no improvement, 
and in 1 the patient died. In 15 cases the resection of the nerve 
was supplemented by division of cervical nerves ; 10 of these 
were cured and •") were improved. In 2 others the sternomastoid 
muscle was divided. 

Irregular and Exceptional Forms of Torticollis. 

Paralytic Torticollis. One or more of the muscles of tin; 
Deck may be paralyzed, a- from anterior poliomyelitis, and thus 
a deformity, dm- at first to simple weakness and later to the 
permanent effects of the disability, may be the result. 

1 American Journal of the Medical Sciences, 1896. 

1 Zur I tfttcom, Heithige zur klin. Chir., 1900, Bd. xxvi. 



646 

Diphtheritic Paralysis and Torticollis. The muscles of the 
neck may be involved iii paralysis following diphtheria. In this 
form the trapezii muscles are, as a rule, affected, so that the 
head bangs forward, but occasionally the paralysis may be accom- 
panied by contraction of one of the sternomastoids. The history, 
the evident weakness, and the paralysis of the soft palate or other 
parts, which is often present, usually make the diagnosis clear. 

Cervical Opisthotonos. In the course of certain forms of dis- 
ease of the nervous system, for example, cerebrospinal or basilar 
meningitis, the head may be drawn backward by spasm of the 
posterior muscles. A slight degree of the same deformity is 
sometimes seen in ill-nourished infants not suffering from serious 
disease. This and the preceding distortion are of some impor- 
tance, because they may be mistaken for symptoms of Pott's 
disease and they have been described in that connection. (See 
page 62.) 

Rhachitic Torticollis. During the course of acute rhachitis, 
particularly when the characteristic deformity of the lower part 
of the spine is well marked, the head may be tilted backward 
usually as a compensatory attitude, but occasionally slight spasm 
of the posterior muscles may increase the distortion ; so, also, 
when lateral deviation of the spine is present due to rhachitis the 
neck may participate in the deformity as in other forms of rotary 
lateral curvature. This is not torticollis, however, in the proper 
sense. 

Ocular Torticollis. Several cases have been recorded in which 
the head was habitually held in a distorted attitude because of 
defective vision or irregularity in the action of the muscles of the 
eyes. This is, however, rather an improper attitude than a 
variety of true torticollis 1 (Fig. 154). 

Psychical Torticollis. A distortion of the head, apparently 
due to the inability of the patient to control the muscles of the 
neck, has been described by Brissaud. 2 The deformity was not 
due to muscular spasm, since it could be corrected by the pressure 
of a finger on the head. The condition is called by Brissaud a 
local paralysis of the will — a form of neurosis allied to neuras- 
thenia, epilepsy, and functional spasm. 



1 Medical News, June 11, 



p. 772. 



These de Paris, 1894. 



CHAPTER XX. 



DISABILITIES AND DEFORMITIES OF THE FOOT. 
General Description of the Foot and of its Functions. 

The function of the foot is twofold : to serve as a passive 
support of the weight of the body, and as an active lever to raise 
and propel it. For the proper performance of these functions 
the foot is constructed to allow elasticity under pressure, and an 
alternation of attitudes under strain, that protect it from injury. 

The Arches. The most noticeable peculiarity of the foot is 
the arrangement of its arches. As has been suggested by Ellis 
and others, the construction and shape of the arched part of the 



Fig. 375. 




Longitudinal section of the cast of the arch at the point A in Fig. 376. A, the astragalo- 
scaphoid junction ; B, the internal tuberosity of the os calcis ; C, the head of the first meta- 
tarsal bone. 

foot may be better understood by considering it as half of the 
arch formed by the two feet. This complete arch may be demon- 
strated by making an imprint of the apposed feet in plaster of 
Pari-. The plaster cast which represents it will appear in shape 
somewhat like an inverted saucer, the part of each foot that rests 
npon the ground forming half of an irregular ring. If the plaster 
cast is -awed into equal sections it will be seen that the highest 
or thickest part of each division is at the astragaloscaphoid junc- 
tion : from this point the arch descends sharply to the tuberosities 
<.f the oe calcis, and gradually to the outer border, beneath the 
cuboid bone, and to the metatarsophalangeal joints (Fig. ;>75). 
A cross-section of tli<- cast will show the contour of what is some- 
times called tin* transverse arch (Fig. 376), while the section 
through the long diameter will demonstrate the shape of the 



648 



ORTHOPEDIC SURGERY. 



longitudinal arch. In descriptions of the longitudinal arch it is 
often divided into two parts, of which the outer division is formed 
by the oa ealcis, the cuboid, and the two outer metatarsal bones. 
Of this outer arch, the highest point is at the calcaneocuboid 
articulation (Fig. 377), and although it is normally a permanent 
arch, yet the soft tissues are forced downward beneath it when 



Fig. 376. 




Cross-section of the cast of the arches of the apposed feet. A, the internal and 
inferior surface of the astragalonavicular junction. 

weight is borne, so that the outer border of the foot makes an 
Imprint throughout its entire length, as contrasted with the inner 
and deeper arch formed by the os ealcis, the astragalus, the 
navicular, the cuneiform, and the three inner metatarsal bones 
(Fig. 378). This division, although an artificial one, is of some 
service in calling attention to the fact that the outer or lower 



Fig. 377. 




The bones of the right foot, viewed from the outer side. (Testut, from Gerrish's Anatomy.) 

arch is more solidly braced, and, therefore, better adapted for 
continuous weight bearing than is the higher and more elastic 
inner arch. 

The diagram of the longitudinal arch, showing its sharp 
descent from the highest point to the centre of the heel, indicates 
that the heel is well adapted for weight bearing, while the long 
anterior pillar composed of several bones is less strong but more 



DISABILITIES AND DEFORMITIES OF THE FOOT. 649 

elastic ; thus one instinctively extends the foot in descending 
stairs, for example, to avoid the unpleasant jar of direct shock 
received upon the heel. Of this anterior pillar, the third meta- 
tarsal bone is the most direct support, while the more movable 
first and fifth metatarsals, more under muscular control, aid in 
balancing the weight and sustaining it in the different attitudes. 

Both divisions of the longitudinal arch are permanent arches, 
but there are two others which are obliterated under weight — one 
of these is that formed by the heads of the metatarsal bones, the 
anterior metatarsal arch. In the unweighted foot the second and 
third metatarsal bones occupy a higher plane than their fellows, 
but when the erect posture is assumed the anterior arch is 
depressed to allow all the metatarsal heads to bear their share of 
the weight. The other arch does not rest upon the ground, but 



Fig. 378. 




The bones of the right foot, viewed from the inner side. (Testut, from Gerrish's Anatomy. 



is formed by the internal border of the foot, which curves slightly 
outward, so that when the two feet are placed side by side an 
interval remains between them, widest at the highest point of the 
longitudinal arch, as is shown in the diagram by the upright sec- 
tion which divides the cast of the two soles from one another, 
the internal arch (Fig. 370). When the weight is borne this 
curved contour of the foot becomes straighter, or is obliterated, 
or La even transformed to an arch whose convexity is internal 
Fig. 396). 
The Foot as a Passive Support. The foot is supported by 
the muscles, by ligaments, and by the strong plantar fascia that 
cover- in the Bole. WIm-d the foot is actively used it is in great 
part supported by the muscles, but when it serves as a passive 
support, aa in standing, the ligaments bear the greater part of the 
-train, and its normal elasticity allows the bearing surface to 



650 ORTHOPEDIC SURGER Y. 

expand slightly as the arches are slightly depressed. If this 
normal elasticity is diminished, as is sometimes the case, the sup- 
ports of the arch are subjected to abnormal pressure and the 
individual may suffer from sensitive corns or calloused skin 
beneath the bones (Fig. 418). Or if the ligaments allow ab- 
normal expansion the arches may become permanently depressed, 
and, as a result, the range of motion necessary to the proper 
functional use of the foot may be permanently restricted (Fig. 
398). 

When the statement is made that the foot broadens and that the 
arches are slightly depressed under weight, it must not be under- 
stood that the longitudinal arch is simply flattened by direct 
pressure and by elongation of elastic ligaments and fascia. Liga- 
ments and fascia are not elastic in this sense, and they are not, in 
the normal foot, overstretched. The change in contour is the 
effect of normal motion in the joints of the foot, by which it is 
placed in the most favorable attitude for weight bearing without 
muscular exertion — the so-called attitude of rest. 

Of the changes of contour that distinguish the foot used as a 
passive support from the one that bears no weight, the most 
significant is the obliteration of the outward curve of its internal 
border. This change is due to the fact that the astragalus, bear- 
ing the leg, rotates inward and downward on the os calcis until 
it is checked by the resistance of the ligaments and by the inter- 
locking of the bones. The head of the astragalus thus becomes 
slightly prominent, the inner border of the foot is depressed, and 
an attitude is attained in which the weight of the body may be 
supported with but slight muscular exertion. In this attitude of 
rest, as von Meyer has explained, there is general fixation of 
joints of the lower extremity which makes support possible with 
the least muscular exertion. The pelvis tilts slightly backward 
until tension is brought upon the anterior part of the capsule of 
the hip-joint ; the femur rotates slightly inward on the tibia, 
which in turn falls slightly inward upon the everted foot. To 
unlock the joints the pelvis must be tilted forward or the hip 
must be flexed. 

The Foot in Activity. The second function of the foot is as 
a lever to raise and to propel the body. The calf muscles supply 
the power and the heads of the metatarsal bones serve as the 
fulcrum on which the weight is to be lifted. When the foot is 
used as a lever, it should be held in such relation to the leg that 
the line of weight, passing downward through the centre of the 



DISABILITIES AXD DEFORMITIES OF THE FOOT. 651 

knee and ankle-joints, is continued over the second toe or practi- 
cally the centre of the foot. As the body is lifted over the 
fulcrum the leg is turned outward in its relation to the forefoot, 
because the inner side of the fulcrum, formed by the first meta- 
tarsal bone, is longer than its outer side ; thus the strain is 
directed toward the outer and stronger side of the foot (Fig. 379). 

In the proper walk, which is the best illustration of the lever- 
age function, the feet should be held practically parallel to one 
another, so that the line of strain may fall through the centre of 
the foot. As one foot is advanced it first bears weight momen- 
tarily on the heel, then upon its outer border ; the heel is then 
raised, and the body is lifted over the toes, the great toe giving 
the final impulse to the step, so that if the walker is looked at 
from behind he appears to be in-toeing at the termination of 
each step. Thus, during the walk, there is an alternation of 
postures, and the foot, under muscular control, assumes the 
attitudes most opposed to that of passive support. 

Improper Postures. The alternation of postures and the lever- 
age action of the foot are by no means necessary to simple 
progression ; for example, both feet might be fixed in plaster 
bandages, yet walking would be possible, just as it is possible 
on two wooden legs. Indeed, an approximation to such a manner 
of walkiug is often seen, in which the feet are practically held 
in the passive attitude, the weight being borne upon the heels. 
Such a walk is necessarily jarring and ungraceful, and if it is 
not the result of weakness and deformity it predisposes to them 
because of the disuse of proper function. 

One means of making the leverage function difficult is the 
custom of turning the feet outward. Outward rotation of the feet 
Lb normal in the passive attitude of weight bearing, because it 
enlarges the base of support, locks the joints, and throws the strain 
upon the ligaments to relieve the muscles. On this very account 
it is the improper attitude for activity because the strain falls 
upon the inner border of the foot, or to the inner side of the ful- 
crum, and makes the proper exercise of muscular power and 
alternation of postures impossible. In other words, the attitude, 
normal when the foot is used as a passive support, is abnormal 
when it is in active use. 

The Movements of the Foot. The junction between the foot 
and the leg is made by means of the astragalus, a bone which is 
not intimately connected with cither part, since it moves upon 
the leg and upon the foot, and to it no muscles are attached. 



652 



ORTHOPEDIC SURGERY. 



The primary movements of the foot are four in number — dorsal 
flexion, plantar flexion, adduction, abduction. 

Simple dorsal and plantar flexion are confined to the ankle- 
joint, but complete plantar flexion is combined with slight adduc- 
tion, and dorsal flexion with abduction, because the external facet 
of the astragalus allows a greater range of motion on the external 
malleolus than is permitted about the internal malleolus. 

The range of motion at the ankle-joint is from sixty to eighty 
degrees; thus dorsal flexion to ten or twenty degrees less than 



Fig. 379. 



Fig. 




Illustrating the involuntary adduction 
of the forefoot, due to the obliquity of 
the bearing surface of the metatarsus, 
in the proper attitute for walking. 



The improper attitude of outward rotation, 
in which there is disuse of the leverage 
function. 



the right angle, and plantar flexion to fifty to sixty degrees more 
than the right angle (Figs. 381 and 382). 

Adduction and abduction of the foot are carried out in the 
mediotarsal and subastragaloid joints. 

Adduction, the motion of turning the foot inward in its relation 
to the leg, is always accompanied by inversion of the sole or 
supination, because of the shape of the joint surfaces between the 
astragalus and os calcis, where the greater part of the motion 
takes place. Simple adduction and abduction without supination 
or pronation is possible to a very limited extent in the medio- 



DISABILITIES AND DEFORMITIES OF THE FOOT. 653 

tarsal joint. Its range niav be tested by fixing the heel, when 
the forefoot may be moved slightly from side to side upon the 
astragalus and os calcis. The range of motion in the sub- 
astragaloid joint is twice as free as in the mediotarsal joint. The 
character of the motion between the astragalus and os calcis is 
rotation on an axis passing through the upper and inner part of 
the head of the astragalus, downward and outward to the outer 
tuberosity of the os calcis. Thus for all practical purposes 
adduction, inversion, and supination are synonymous terms, as 
are abduction, pronation, and eversion. 



Fig. 3S1. 



Fig. 382. 





Voluntary dorsal flexion. Voluntary plantar flexion. 

In these attitudes the astragalus moves with the foot upon the leg bones, as contrasted with 

adduction and abduction, in which the centre of motion is below the astragalus. 



In the movement of adduction of the foot the astragalus is 
fixed between the malleoli, and upon it the os calcis glides for- 
ward and its anterior extremity turns slightly inward; the 
sustentaculum tali moves backward, its inner superior surface is 
elevated, and it- external surface is depressed. Meanwhile the 
forefoot, following the motion of the os calcis, is carried inward 
about the head of the astragalus; its inner border is elevated, 
and it- outer bonier La depressed, so that the sole looks inward 
and downward. In this attitude all the arches are increased in 
depth | Fig. •;- 

In abduction the bonet! move upon one another in the reverse 



654 



ORTHOPEDIC SURGERY. 



.Unction, the curves are lessened, and that of the inner border is 
obliterated (Fig. 384). 

The extreme of adduction is only attained in the position of 
plantar flexion, because in this position the adduction possible at 
the ankle-joint, in part due to the contour of the astragalus and 
in part to the greater mobility allowed in the joint when the 
narrow posterior border of the astragalus is alone in contact with 



Fig. 383. 



Fig. 384. 





Voluntary adduction. Voluntary abduction. 

In these postures the foot moves upon the astragalus, which is practically fixed between 
the malleoli. Adduction, the turning of the foot inward in its relation to the leg, is always 
accompanied by elevation of its inner and depression of its outer border. This is known 
as supination or inversion of the foot. The reverse of this attitude— pronation or eversion— 
is an accompaniment of abduction, as is illustrated in the figures. 

the malleoli, is added to the adduction which the joints of the foot 
permit. 

Extreme abduction is attained in the attitude of dorsal flexion, 
its extent being about one-half that of adduction; the entire 
range of motion between the two extremes being about forty-five 
degrees. 

In this description the foot is considered as moving on the 
leg, but in the attitude of rest the foot becomes the fixed point 



DISABILITIES AXD DEFORMITIES OF THE FOOT. 655 

and the astragalus moves upon the os calcis in the manner and to 
the position already mentioned in the description of abduction — 



Fig. 385. 



Fig. 386. 





The direct dorsal flexors. 

Tibialis ante: ratline and PefOlietlfl tertius of right side ; outline and 

attachment area 1 -. attachment areas. (Gerrish.) 



1. e. f it -lip- downward and forward and turns inward, and at the 
time the anterior extremity of the oe calcis turns slightly 



Fig. 387. 



Fig. 388. 



/: 



/ 



/ 



The calf muscle. The plantar flexor. 
Gastrocnemius of right side ; outline and Soleus of right side ; outline and attach- 

attachment areas. (Gerrish.) ment areas. (Gerrish.) 



DISABILITIES AND DEFORMITIES OF THE FOOT. 657 

inward and downward, and its inner border is depressed. Corre- 
sponding to this movement, as the inner border of the foot 



Fig. 389. 



Fig. 390. 





The direct abductors. 
Peroneos longus of right side ; outline Peroneus brevis of right side ; outline and 

and attachment areas. (Gerriah.) attachment areas. (Gerrish.) 

becomes straight or bulges inward, the navicular is forced forward 
and downward and the longitudinal arch is depressed. A.s has 

42 



658 



ORTHOPEDIC SU1WERY. 



Fig. 891. 



\ 



The most important adductor. 
Tibialis posterior of right 
side ; outline and attachment 
areas. The most of the muscle 
is represented as if seen 
through the bones. (Gerrish.) 



been mentioned, the turning of the" leg 
inward and the corresponding turning of 
the foot outward in its relation to it locks 
in a manner the ankle-joint, and at the 
same time throws the strain upon the liga- 
ments, so that standing in the erect posture 
is possible with but little muscular exertion 
(Fig. 396). 

To put it in a simpler manner, the leg 
supporting the weight of the body has a 
tendency to tilt the foot over toward the 
inner side and to evert the sole ; thus, un- 
der increasing superincumbent weight, the 
point of greatest pressure on the sole shifts 
from its centre and outer border toward 
the inner border. If, on the other hand, 
the body is raised upon the toes, the arch 
is relieved from strain and the weight falls 
upon the front and outer part of the foot. 
Plantar flexion and adduction represent, 
as contrasted with the passive attitude of 
supporting weight, the attitude of activity 
in which the foot is supported and con- 
trolled by the muscles. 

The Function of the Muscles. The 
most important function of the dorsal 
flexors is to lift the foot as it is swung for- 
ward of the plantar flexors, to serve in the 
active propulsion of the body. The differ- 
ence in function is shown by the relative 
strength of the two groups, the plantar 
flexors being five times the stronger; in 
fact, the calf muscle (gastrocnemius and 
soleus) alone is three times as strong as all 
the other muscles of the foot combined. 
It is practically the leverage muscle, the 
others serving more especially to fix and to 
hold the forefoot, or fulcrum, in its proper 
relation to the leg. It is also a powerful 
adductor and supinator of the foot in the 
attitude of plantar flexion (Figs. 387 and 

The muscles that most directly support 
the inner arch of the foot are the tibialis 



DISABILITIES AND DEFORMITIES OF THE FOOT. 659 

posticus and tibialis anticus, whose tendons meet in their in- 
sertions in front of the astragalus in the form of a V. The 
tibialis anticus supports the internal border of the foot from 
above, and is the direct supinator of the foot in dorsal flexion 
— that is, if unopposed it elevates the inner border of the foot, 
when it acts as a dorsiflexor. The tibialis posticus is the most 
powerful adductor (Figs. 385 and 391). The extensor longus 
hallucis is an adjunct of the tibialis anticus in its action on the 
foot as a whole. The extensor longus digitorum, including the 
peroneus tertius, is a dorsal flexor and abductor. 

The flexor longus hallucis, passing directly beneath the sus- 
tentaculum tali, aids in supporting the weak part of the foot and 
its position demonstrates the importance of the proper functional 
use of the great toe (Fig. 395). 

The peroneus longus and brevis support the outer arch, and 
the former binds the foot together and holds the great toe firmly 
against the ground ; thus it indirectly supports the longitudinal 
arch against direct pressure (Figs. 389 and 390). They also serve 
as abductors and pronators. 

The relative strength of the muscles and their functions is 
shown in the following tables : l 

Dorsal Flexors of the Foot; Strength Reckoned in Kilo- 
grammetres. 

Tibialis anticus 0.871 

Extensor longus digitorum 0.280 

Extensor longus pollicis 0.155 

Peroneus tertius 0.087 

1.393 

Plantar Flexors. 

The call f Soleus 3.256 

muscle, i Gastrocnemius 2.831 

Flexor longus pollicis 0.218 

Peroneus longus 0.118 

Tibialis posticus 0.094 

Flexor longus digitorum 0.078 

Peroneus brevis 0.055 

6.650 

Relative Strength of the Supinators of the Subastragaloid 

Joint. 

Weight of the 
Strength. muscles. 

3oleofl 1.021 157.0 grammes. 

Gastrocnemius 0.709 120.0 

Tibialis posticus 0.337 39.6 

Flexor longus pollicis 0.172 33.2 

Flexor longus digitorum 0.123 12.3 

2.362 362.1 



1 Leber die Arbeitsleistung der auf die Fussgelenke Wirkenden Muskeln, R. Fick, Leipzig, 



660 orthopedic surgery. 



Relative Strength of the Pronators of the Subastragaloid 

Joint. 

Weight of the 
Strength. muscles. 

lYroneus longus 0.282 24.0 grammes. 

Peroneus brevi6 0.192 16.5 " 

Extensor longus digitoruru .... 0.164 18.2 " 

Peroneus tertius 0.067 3.5 " 

Extensor longus pollicis 0.045 12.3 " 

Tibialis anticus 021 49.2 " 

0.771 123.7 

Relative Strength of the Supinators of the Mediotarsal Joint. 

Tibialis anticus 0.238 

Tibialis posticus 0.078 

Flexor longus pollicis 0.034 

Flexor longus digitorum 0.033 

Extensor longus pollicis 0.030 

0.413 

Relative Strength of the Pronators of the Mediotarsal Joint. 

Peroneus longus 0.162 

Peroneus brevis 0.090 

Extensor longus digitorum 0.085 

Peroneus tertius 0.033 

0.370 

It will be noticed that the strength of the pronators and 
supinators (abductors and adductors) of the mediotarsal joint is 
nearly equal, and that the great preponderance of power of the 
supinators of the subastragaloid joint is owing to the fact that the 
calf muscle is a supinator. When the foot is at a right angle 
with the leg, the power of the calf muscle not being utilized, the 
pronators are stronger than the supinators. It will be noticed, also, 
that the tibialis anticus muscle, which supinates the mediotarsal 
joint, is reckoned among the pronators of the subastragaloid joint. 

The Foot Considered as a Mechanism. In the study of the 
deformities, and particularly of the functional weaknesses of the 
foot, one must never lose sight of the fact that it is a mechanism, 
subject to mechanical laws, and that its deformities and disa- 
bilities, its relative strength or weakness, may be best appreciated 
by comparing it with the normal standard. As in other machines, 
marked deformity or distortion is evident at a glance, even though 
the apparatus is not in use, but functional ability can be judged 
only by the manner in which active work is performed. 

As has been stated, the foot is, in activity, a lever, by means 
of which the weight of the body is lifted and propelled. If it is 
loosely constructed or insufficiently supported by the ligaments, 
ir is evident that it cannot be properly controlled by the muscles. 
If, on the other hand, the muscular power is insufficient, it is 



DISABILITIES AND DEFOBMITIES OF THE FOOT. 661 

evident, also, that the weight of the body cannot be lifted and 
properly balanced upon it. The structure of the foot may be 



Fig. 392. 



Fig. 393. 





Extensor proj.rius haliuc;- le;out- Extensor longus digitorum of right side ; out- 

line and attachment areas. (Gerr. line and attachment areas. (Gerrish. 

normal, and it-« muscles may be of norma] strength, yet the -train 

placed upon it may be disproportionately great. The strain may 

erweight of body, or the overwork of a laborious occupation, 



Fin. :';»!. 



Fig. 395. 




\ 



. 






Flexor longus digitorum of right side ; 
outline and attachment areas. The muscle 
is represented as seen from in front through 
the bones. (Gerrish.) 



Flexor longus hallucis of right side ; 
outline and attachment areas. The 
muscle is represented as seen from the 
front through the bones. (Gerrish.) 



DISABILITIES AXD DEFORMITIES OF THE FOOT. 663 

but more often the machine is overworked simply because it is 
subjected to mechanical disadvantages in the performance of its 
functions, by the assumption of improper attitudes. 

One of the most common of such attitudes is, as has been 
mentioned, that of turning the feet outward in walking ; for as 
the fulcrum is displaced outward, the strain falls through the 
inner and weaker side of the foot. As a consequence of the 
improper attitude there is usually, to a greater or less degree, dis- 



Fig. 396. 



Fig. 




An attitude that simulates the flat-foot. 
- • Fig. 397.) 



Fig. 397, compared with Fig. 396, 
illustrates the voluntary protection of 
the foot from overstrain. 



: the active Leverage function of the foot ; the active lift of 
the call muscle is replaced by exaggerated flexion at the knee, 
the foot being nsed -omewhat as if it were a movable pedestal 
JO). 
Tin- disuse of the active attitude- may be unnecessary, just as 
the outward rotation of the feet with which it is associated is a 
habit, a habit that is often the result of improper teaching. On 
the other hand, the habitual assumption of the passive attitude 



664 



niiTUOPEDIC SURGERY. 



Fig. 398. 




Typical "flat-foot" of moderate degree, 
illustrating the component elements of ab 
ductiou and depression of the arch. 



may be induced by injury or disease of the foot, or by corns or 
bunions, or by improper shoes. Under such conditions the strain 

of the leverage function increases 
the discomfort; consequently it 
is discontinued. It must not be 
inferred that such improper at- 
titudes lead directly to weakness 
and discomfort, for in most in- 
stances an ungraceful carriage 
and gait are the only ill effects. 
The improper attitudes must, 
however, lessen the power and 
resistance of the foot, and they 
must be reckoned, therefore, 
among the predisposing causes 
of disability and deformity. 

The passive attitude, it will 

be remembered, is the attitude of 

rest, in which the ligaments bear the greater part of the strain 

and in which the arches of the foot are depressed or obliterated. 

The Weak Foot. 

Synonyms. Splay-foot, flat-foot. 

The introductory pages lead naturally to the consideration of 
the most important of the acquired disabilities of the foot, a dis- 
ability whose most important characteristic in the mildest and in 
the most advanced type is the persistence of the passive attitude, 
or an approximation to it, in place of active motion and alterna- 
tion of posture. Disuse of function is followed by restriction of 
motion, particularly in the range of adduction and plantar flexion, 
and finally by persistent deformity, a deformity which is simply 
an exaggeration of the normal posture assumed when the foot 
supports weight (Fig. 390). This is the so-called flat-foot (Fig. 
398). At first glance it may seem that the depression of the 
ardi is the most noticeable peculiarity in a well-marked case of 
flat-foot, and that the popular name is, therefore, an appropriate 
one, but on closer examination it will be evident that the normal 
relation between the leg and the foot is changed. This change, 
which, from the functional standpoint, is of far greater impor- 
tant- than the depth of the arch, may be analyzed as follows : 

Anatomy. 1 . The leg is displaced inward, so that the weight 
falls upon the inner side of the foot. 2. The leg is rotated 



DISABILITIES AXD DEFORMITIES OF THE FOOT 665 

inward, so that a line drawn through its centre, prolonged from 
the crest of the tibia, instead of falling over the second toe now 
points inside the great toe, or even over the centre of the internal 
border of the foot (Figs. 398 and 401). 

It has been stated that under normal conditions, in the act of 
passive weight bearing, the astragalus rotates downward and 
inward upon the os calcis, depressing its anterior and internal 
border until the movement is checked by the strong ligaments 
connecting the bones, the calcaneonavicular, the deltoid, and the 
interosseus ; in other words, the leg has a tendency to slip down- 
ward and inward from off the foot. In the weak foot this 
inclination has become an accomplished fact, for the normal 
movement has become so exaggerated by the distention of the 
ligaments and by the weakness of the supporting muscles that 
an actual subluxation is present. The astragalus has rotated and 



Fig. 399. 



Fig. 400. 





The relation of the astragalus to the 
os calcis. 



The relation of the astragalus and os 
calcis in flat-foot. 



dipped far to the inner side of its normal position, to an attitude 
ggerated rotation aud plantar flexion, so that its head can 
be plainly felt on the interual border of the foot. The anterior 
extremity of the OS calcis is depressed and is turned slightly 
inward and it- internal bonier is lowered (Fig. 400). 

The navicular bone has been depressed with the head of the 

gains, although to a less degree, it has been forced further 

from tie- Ofl calcis, and the entire inner border of the foot 

is lowered. Tim- the depression of the arch is always accom- 

! and preceded by a bulging inward of the inner side of the 

The typical flat-foot is, a- it were, broken in the centre (Fig. 
the posterior division having turned inward and downward, 
while tie- forefoot is forced downward and outward. The dislo- 
cation may - extreme that the entire sole of the fool rests 



666 



oirnioPkDic sriwERY. 



upon the ground, and a callus even may be found at the point 
that usually represents the highest point of the arch, which now 
supports the greatest burden. 

In this change of relation between the bones the arched part 
of the foot or waist appears much broader than normal, even 
broader than the front of the foot; the heel projects, the external 
malleolus is depressed and carried forward by the rotation of the 

leg, and is much less prominent 
fig. 401. than normal ; the internal 

malleolus is more prominent, 
and with the astragalus it over- 
hangs the bearing surface of 
the sole. The entire mechan- 
ism is twisted and out of gear ; 
its motion is, therefore, very 
much restricted. It is mani- 
festly impossible for the patient 
to adduct the forefoot — that 
is, to turn it inward about the 
head of the displaced astrag- 
alus. Plantar flexion is also 
much limited, because of the 
persistent adduction and plan- 
tar flexion of the astragalus. 
Dorsal flexion, on the other 
hand, although it is actually 
restricted, may appear to be 
abnormally free, because the 
forefoot is abducted and 
slightly dorsiflexed upon the 
head of the astragalus (Fig. 

Weak feet, showing the inward rotation of 398). 
the legs when the abducted feet are placed side mi -i • i • v, i • , 

by side I he disability and its accom- 

panying deformity are found 
in every grade of severity. Pain begins when, the support of the 
muscles being insufficient, the ligaments begin to give way under 
-train, allowing the bones to occupy an abnormal relation to one 
another. It is evident, therefore, that the individual in whose 
foot the arch is well formed and whose ligaments are firm, will 
suffer from the symptoms of strain long before the arch has been 
depressed or deformity has become apparent ; also, that the lateral 
inward bulging, characteristic of advancing deformity, must be 




DISABILITIES AND DEFORMITIES OF THE FOOT. 667 



Fig. 402. 



very great before the arch is completely flattened. In this type 
the prominent deformity is lateral displacement (valgus). On 
the other hand, if the individual has inherited a low arch, as is 
characteristic of certain races, or if, as the result of weakness in 
early life, the arch has been depressed or has never formed, 
accommodative changes in the bones will have taken place during 
growth, so that the flat-foot of this type will not be attended with 
a- much change in its relation to the leg, and, therefore, disturb- 
ance of function, as in the typical case that has been described. 
This latter class of cases exemplifies the popular type of flat-foot 
that may exist without pain or disability, and in which the most 
noticeable peculiarity is the obliteration of the arch (planus). 
(Contrast Figs. 402 and 404.) 

In certain instances abnormal laxity of ligaments allows 
deformity of the valgus type when weight is borne, yet the foot, 
controlled by efficient muscles, 
may be apparently normal in 
functional ability, while in other 
cases in which the ligaments 
are normal ami yet are subjected 
by insufficient muscular protec- 
tioD to overstrain, disability 
and pain may precede notice- 
able deformity. 

It is evident that the lower- 
ing of the arch is of secondary 
importance in the deformity, 
andthat the popular significance 
«»f painful fiat-foot, as an in- 
herited and irremediable weak- 
ii- ss, is most mish ading. Yet 
ems to have governed the 
treatment of tie- disability until 
very recently. On the one 
hand, the early cases were over- 
Looked because the foot was not flat, while those in which the 
deformity was more advanced were simply neglected or were 
treated by simple supports beneath the an-h or by operation, 

without regard to the LOSS of function, and, therefore, without 

dope of ultimate cure. 

\- has been stated, there is one feature common to every 
grade of the so-called Hat-foot : the fool regarded a- a machine i- 




Weak feet, arch not depressed. 



( ;,;S ORTHOPEDIC SURGER Y. 

weak as compared to the normal standard — weak because of the 
persistence of the attitude of rest and relaxation, as contrasted 
with that of activity and strength, and weak because the proper 
relation between the power and the fulcrum is changed. Even 
the inherited flat-foot or the flat-foot which has never caused 
symptoms is weak in the sense that, in use, it lacks the spring 
and elasticity characteristic of the perfect machine. The term 
weak foot may be used, then, to indicate all types of the disa- 
bility. 

In one weak foot the arch has disappeared (Fig. 398) : in 
another weak foot the arch is of normal depth, but the foot is 
abducted or pronated in its relation to the leg (Fig. 397). In 
one case the deformity appears only under weight; in another 
the foot is held rigidly in the deformed position by muscular 
spasm. In one instance there may be great deformity without 
pain ; and in another disabling weakness and pain without 
noticeable deformity. In one case the foot is unable to perform 
its functions because of its inherent weakness ; in another the 
disability may be due simply to the improper use of a normal 
structure. 

Pathology. Supposing the foot to have been normal before it 
began to break down, it is evident that persistent deformity could 
not have been acquired without marked changes in its internal 
structure. In a general way these changes have been indicated 
already. The ligaments on the internal aspect of the foot and of 
the ankle-joint are weak and distended ; the unused portions of the 
articular surfaces of the joints may be denuded of cartilage, while 
new facets may have formed to accommodate the changed rela- 
tions of the bones. For example, the external malleolus may be 
in direct contact with the os calcis; evidences of injury and of 
abnormal pressure may be found in the thickened periosteum, 
in formation of osteophytes, while the internal structure of the 
bones has been changed in adaptation to the new conditions. The 
muscles which are no longer used in the leverage function, the 
plantar flexors and adductors, have become atrophied, a change 
that i< made evident by the shrunken calf. The muscles on the 
inner border of the foot have been overstretched, while those on 
the upper and outer part have become shortened and contracted. 
Such a foot represents an extreme, it may be an irremediable 
decree of deformity ; but in by far the greater proportion of the 
cases the pathological changes have not advanced to a stage that 
interferes with successful treatment. 



DISABILITIES AND DEFORMITIES OF THE FOOT. 669 

Etiology. In all cases the actual symptoms of pain and dis- 
ability are due to a disproportion between the burden or strain 
and the ability of the machine to perform it. 

This theory accounts for the fact that the weak foot, although 
very common in childhood, does not, as a rule, cause troublesome 
symptoms until adolescence, when the weight and strain put upon 
it are increased. It explains why the foot, which may be fairly 
normal in structure, breaks down often in later adolescence or 
early adult life when the continuous strain of regular occupation 
is undertaken. It is evident, also, that an occupation that 
induces a persistence of the passive attitude, that of waiters, 
3, and bartenders, for example, exposes the feet to greater 
strain than one which encourages alternation of postures. And 
that the symptoms are likely to be more severe and the deformity 
to be greater among those who are obliged to labor than among 
those who are not. Overwork or strain, of occupation or other- 
may be temporarily disproportionate because of general 
weakness, a-, for example, during pregnancy or after recovery 
from exhausting disease ; or because of local injury or disease of 
the foot itself which weakens it directly or induces improper 
attitude-. On this theory one may very easily explain what has 
proved such a stumbling-block for students, viz., that there is no 
constant relation between the degree of deformity and the severity 
of the symptoms, for, although all flat-feet are mechanically weak, 
yet all weak feet are not necessarily painful feet. Pain is not 
caused because the foot is flat ; it is a symptom of progressive 
deformity and of strain and injury to the joints. The progress 
of the deformity may be temporarily or permanently checked at 
-ML r »-. either by removal of the exciting cause or because 
of the resistance of the tissues ; then the pain intermits or ceases. 

This conception of the foot as a mechanism, of which grades 
•y may !»<• recognized, has a great advantage, since it 
enable- one to perceive wherein a foot i- weak, even though the 
weakness causes no symptoms whatever, and thus to prevent dis- 
comfort and deformity by a recognition of its predisposing causes. 
Finally from tin- standpoint one cannot fail to appreciate the 
importance of improper shoes in the etiology of this and of all 
form- of acquired weakness "f the feet, a subject to which 
ial attention will be called in another section. 

Statistics. A brief analysis of 1000 cases of so-called flat-foot 
the Hospital for Raptured and Crippled will represent 
fairly the points of genera] interest in this class of cas 



670 ORTHOPEDIC SURGERY. 

The Age and Sex of the Patients. 

Age. Males. Females. Total. 

Ten years or less 68 30 98 

Ten to fifteen 112 87 199 

Fifteen to twenty 144 83 227 

Twenty to twenty-five 94 53 147 

Twenty-five to thirty 68 41 109 

More than thirty 132 88 220 

618 382 1000 

Foot affected: right, 133; left, 138; both, 729. 

]n 58 cases the cause of the disability appeared to be injury, 
and in 65 instances it was, apparently, due to rheumatism or to 
rheumatoid arthritis. The symptoms usually appear first in one 
foot, and, as a rule, they are at all times more marked on one 
side. Of 569 instances, in which the duration of symptoms was 
recorded, it was six months or less in 409. 

The age of the patients is of interest as bearing on the question 
of prognosis ; 426 were between ten and twenty years of age, and 
780 were less than thirty. 

Hospital statistics cannot adequately represent the subject, for, 
as a rule, it is because of disability and pain that these patients 
apply for treatment. In the larger proportion of the cases 
recorded muscular spasm and rigidity were present, in 234 
instances to such a degree that forcible overcorrection was 
advised — an operation rarely necessary in private practice. 

It is in childhood that the prevention of subsequent weakness 
and deformity is of the first importance, yet but 98 children of 
ten years of age or less are recorded, and many of these were 
brought, not for weakness or deformity, but for treatment of the 
symptomatic in-toeing. 

Symptoms. As has been stated, the symptoms of the weak 
foot, although similar in type, vary in severity according to the 
local condition and the disturbance of function, the work to be 
performed, and the susceptibility of the individual. The earliest 
symptom is usually a sensation of weakness ; the patient begins 
to recognize as familiar a feeling of discomfort, of tire and strain 
about the inner side of the foot and ankle ; sometimes after long 
standing a dull ache in the calf of the leg or pain at the knee, 
hip, or id the lumbar region, symptoms more common in women 
than in men ; or after overexertion a momentary sharp pain radi- 
ating from the point of weakness ; thus the patient often dates the 
history of his trouble from a long walk or other form of over- 
work. A fter a time the patient may become aware that he is accom- 
modating his habits to his feet ; he rides when he once walked ; he 



DISABILITIES AXD DEFORMITIES OF THE FOOT. 671 

sits when he once stood ; he no longer runs up or down stairs or 
jumps off the street-car. His feet have lost their spring, as he 
expresses it. which means that the foot is no longer supported and 
controlled by muscular activity and is no longer used as a lever. 
Xot infrequently early symptoms are pain and tenderness at the 
centre of the heel, explained in part by the jarring heel walk which 
is always assumed when the foot is weak, and in part by the strain 
upon the attachments of the deep plantar ligaments. The patient 
may complain that he cannot buy comfortable shoes ; the reason 
is that the weak foot under use is changed in shape, so that the 
shoo that was comfortable in the morning compresses the foot 
painfully at night ; thus increasing discomfort from corns, bunions, 
painful great toe-joints, and deformities of the toes is experienced. 
Coldness ami numbness, congestion and increased perspiration, 
caused by the impaired circulation and weakness, are common 
symptoms in this class of cases. Actual pain is, as a rule, felt 
only when the foot is in use ; it ceases under temporary rest or 
relief from disproportionate work, and it is this remittance of 
symptoms, together with the fact that the discomfort is usually 
more marked in damp weather, that leads so often to the mistaken 
diagnosis of rheumatism. The foot is weak and vulnerable ; the 
patient recognizes the fact that he has what he speaks of as a 
weak ankle, or sprain, or gout, or rheumatism, but if he has 
accommodated himself to the weakness but little discomfort is 
experienced. In many instances such relief or accommodation is 
impossible, and it is, therefore, among the working class that one 
oftener sees the frank and rapid development of the disability 
and deformity. The range of motion becomes more and more 
restricted ; the habitual attitude, at first exaggerated to deformity 
only under the influence of the weight of the body, remains as a 
permanent displacement of the bones. The weak and dislocated 
foot i- subjected to constant injury, to what may be likened to a 
ision of Blight sprains, so that local congestion, tenderness, 
and swelling may anpcai" together with muscular spasm, rigidity, 
ami pain on passive motion. localise of this rigidity of the foot, 
which has Lost the power to accommodate itself to inequalities of 
the surface, the patient dreads to em— a rough pavement, for 
py misstep i- a source >>f pain. Another symptom, tin- dis- 
comfort felt in changing from a position of rest, to activity, 
which is usually present in slight degree at every stage, now 
becomes more prominent. The patient, after sitting or on rising 
in the morning, is unable to walk, but staggers or limp- for 



S72 oirruoriwic surgery. 

several minutes, a Bymptom explained by the fact that when the 
foot is at rest then 1 is a partial reposition of the displaced bones, 
which must again be forced into the deformed posture that has 
become habitual. The local tenderness and muscular spasm are 
increased by use, so that the patient may have difficulty in 
removing the shoe at night, and the symptoms relieved by the 
rest of Sunday become progressively worse during the week. 
The pain and discomfort are more general in character, and are 
often referred to the dorsum of the foot, representing muscular 
rigidity and tension, and to the ankle where the external malle- 
olus is grinding out a facet in the projecting os calcis. The 
patient may now complain of discomfort in the feet and cramps 
in the legs, even when in bed, and the appearance of weakness, 
awkwardness, and depression of spirits may be so noticeable 
that the case is sometimes mistaken for serious disease of the 
nervous system. 

The appearance of such a foot has already been described, and 
the effect of the deformity on its functions should be evident. 
The gait is slouchy and cloddy, what has been spoken of as the 
pedestal walk ; the feet are simply pushed by one another, in 
the attitude of eversion, the knees are slightly flexed and the 
weight is borne entirely upon the posterior segment of the foot. 
The muscles have atrophied, the foot is cold and congested from 
its continued inactivity, and it is usually bathed in perspiration. 
A certain range of motion remains at the ankle-joint, but adduc- 
tion is absolutely restricted by the shortened and spasmodically 
contracted muscles on the outer and upper surface. This type 
represents, of course, only the severe variety that is more likely 
to be seen in hospital than in private practice ; and it would 
seem, were it not for the evidence to the contrary which the 
histories of the patient present, that the nature of the trouble 
must be recognized at a glance. But in the milder and earlier 
cases the diagnosis is not always so easily made. 

Diagnosis. In all cases of suspected weakness of the foot a 
thorough and orderly examination should be made, not only of 
it- appearance, but also of its functional ability and of the manner 
in which it is used. Such an examination is not merely for the 
purpose of diagnosis, which is usually apparent, but in order that 
the amount and character of the temporary or permanent changes 
in structure and function may be properly estimated. 

Attitudes. One begins the examination by noting the manner 
of standing and walking. The heel walk, the exaggerated turn- 



DISABILITIES AND DEFORMITIES OF THE FOOT. 073 

ing out of the feet, the slouchy gait in which the leg is never 
completely extended, in which the power of the calf muscle is 
not applied, and in which the essential postures of the foot are 
disused, are all elements of weakness that should be corrected 
whether they cause symptoms or not. 

Distribution of Weight and Strain. The distribution of the 
weight of the body and the habitual use of the foot are often 
made evident by examining the worn shoe. If it is bulged inward 
at the arch or worn away on the inner side of the sole it shows 
weakn — g. 405). The same observations are then made on 
the bare feet, particular attention being paid to the line of strain 
or leverage ; thus a line drawn down to the crest of the tibia from 
the centre of the patella, continued over the foot, should meet the 
interval between the second and third toes ; if it falls over or 
inside the great toe, it shows that the foot is working at a 
disadvantage (Fig. 401). 

Contour. The contour of the foot should then be examined; 
its internal border should curve slightly outward, so that if the 
feet are placed side by side with the toes and heels in apposition 
a slight interval remains between them; if this slight concavity 
is replaced by a noticeable convexity when weight is borne the 
foot is weak (Fig. 402). This change in coutour is the earliest 
and sometimes the only evidence of deformity. The arch of the 
foot, properly protected by the muscles and by a proper attitude, 
-ink- but slightly under weight ; there is a slight elasticity only, 
as tli«' -train is thrown more to the inner side of the median line, 
and if the depression is marked it shows weakness. 

Bearing Surface. The exact amount of bearing surface may be 
shown by an imprint upon carbon paper or by smearing the sole 
with vaseline; then, as the patient stands upon a sheet of white 
paper, the outline of the foot should be traced so that the relative 
;' the imprint to that of the foot may be shown and compared 
with the normal standard. 

Another method i- that suggested by Lovett. The patient 

'!i a square <>f plate L r] a . s fi xec | j n a table, so that by 

means of a mirror beneath the bearing surface may be examined 

under different d i pressure and in different attitudes 

_. 107 . 

The Range of Motion. The balance of the foot, ;;- shown by 

the range of motion, i- next to be tested, for it- Limitation i- one 

of tie- earliest signs of improper attitudes and of weakness. This 

of motion varies somewhat within normal limit- ; it i- 

43 



67 I ORTHOPEDIC SURGERY. 

usually greater iu childhood than in adult life, greater in the 
slender than in the massive foot, and greater in the foot used 
properly than in one that is not. The first test is applied to 
simple dorsal and plantar flexion ; the leg must be fully extended 
at the knee; the line of strain must be in its normal relation, so 
that the foot may be neither adducted nor abducted, and the 
observation must be made on its outer border. 

In this position the patient should be able to flex the foot from 
ten to twenty degrees less than the right angle, and to extend it 
from forty to fifty degrees beyond the right angle, the range of 
motion being from fifty to sixty degrees (Figs. 381 and 382). 

By far the most important test is that of the power of adduc- 
tion or inversion of the foot, the test of the mediotarsal and 
subastragaloid joints, a motion in which the os calcis is drawn 
forward and inward under the astragalus, while the forefoot is 
flexed about its head. With the leg extended and the patella in 
the median line the foot is turned inward as far as possible ; the 
elevation of its inner border or supination and the turning in of 
the heel are well illustrated in Fig. 383 ; the actual range of 
adduction is somewhat difficult to measure, but it is about thirty 
degrees. Even the mild and early cases of weak foot usually 
show some limitation of this most important motion, and in many 
instances it is completely lost, the patient turning the entire leg 
in the effort to adduct the foot. The less important motion of 
abduction may be tested also (Fig. 384) ; its range is about half 
that of adduction, so, also, the range of supination or inversion of 
the sole is nearly twice as great as that of pronation or eversion 
of the sole. In other words, the internal border of the foot can 
be raised twice as far from the floor as can the external border. 
The range of passive motion is then tested by pushing the foot in 
all directions. The range of dorsal flexion is from five to ten 
degrees beyond that of voluntary motion, while passive extension, 
so far as it applies to the ankle-joint, is about the same as the 
voluntary, although the forefoot may be still farther bent down- 
ward at the mediotarsal joint. The limit of passive adduction is 
considerably beyond that of voluntary inversion. 1 

Passive motion serves several purposes; contrasted with the 

1 As adduction and supination and abduction and pronation are always combined, one 
term is used to Signify the movement inward or outward ; thus, supination means adduc- 
tion , abduction implies pronation. A fixed attitude of adduction and supination is called 
varus ; a fixed attitude of abduction and pronation is called valgus. Varus and valgus sig- 
nify, therefore, deformity. Thus the term valgus, although it maybe properly applied to 
designate the deformity of weak foot, is usually reserved for the more extreme distortion of 
talipes. (8ee Figs. 383 and 384.) 



DISABILITIES AND DEFORMITIES OF THE FOOT. 675 

range of voluntary motion it shows the habitual use of the foot, 
since the motion least used is most limited. It also makes evi- 
dent the slight restriction of motion and the presence of local 
tenderness, which, even in early cases, are usually present. 
Thus, if pressure is made just in front of and below the internal 
malleolus, at the astragalonavicular junction, and if at the same 
time the foot is forcibly adducted, the patient will complain of 
pain at the point of pressure and of a feeling of constriction and 
ten-ion about the dorsum of the foot before the normal limit of 
motion is reached. When the foot is dorsiflexed the plantar 
fascia is put upon the stretch, and its condition may be noted, 
for a contracted and sensitive plantar fascia may cause sufficient 
- mfort to induce improper attitudes and thus it may predis- 
pose to further disability. 

Varieties. This mode of examination will demonstrate the 
disability, and the secondary changes in the mechanism, which 
most be overcome before a cure can be accomplished. By it one 
will learn to recognize several grades of weak foot : 

1 . The normal foot improperly used, as shown by the manner 
«»f standing and walking (Fig. 375). 

_'. The foot, which because of laxity of ligaments or insufficient 
muscular support, is forced by the weight of the body into an 
attitude <>f deformity ; that is, in which the foot under weight 
fall- into an abnormal attitude of abduction in its relation to the 

- evidenced by the inward projection of its inner border and 
by the overhanging internal malleolus, showing that the leg has 
been displaced inward on the foot. As a rule, there is sufficient 
laxity of Ligaments to allow a depression of the arch, as shown by 
the imprint, but in other instances, although the arch seems lower 
because of the characteristic attitude of pronation, in which the 
a is it irere, overhangs the foot, yet the imprint shows that 

is do increase in the area of bearing surface. Indeed, if the 
aversion i- sufficient to raise the outer border of the foot, this may 

■ II smaller than normal ; thus, an individual may suffer from 

I'd flat-foot whose arch i- actually exaggerated (Fig. 397). 

The weak foot, whieh -how- typical deformity under use 

and in whieh the range of voluntary motion i- somewhat limited, 
ilarly in tie- direction of plantar flexion and adduction. 

ed motion causes discomfort and pain, indicating a certain 
permanent accommodative change in structure, whieh i- not 
rent when the foot i- not in use (Fig. '■'>')<'>). 
l. Tie- foot whieh presents typical and permanent deformity, 



676 orthopedic srnuERY. 

whether it is in use or not, and in which the range of both volun- 
tary and passive motion is much restricted. In all of these varieties 
the improper functional use of the foot, particularly the loss of 
active Leverage, is very evident when the patient walks (Fig. 405). 

Limitation of Motion and Muscular Spasm. Limitation of motion 
is caused by the accommodative changes in structure to the 
habitual postures or to the deformity. These are first evident in 
the muscles and ligaments, and, finally, in the articular surfaces 
of the bones. Added to this underlying limitation of motion 
there is usually a certaiu degree of muscular spasm, which varies 
in degree with the local congestion, irritation, and inflammation 
of the joints and tissues. In the quiescent flat-foot it may be 
absent, but on renewed injury or overwork of the weak structure 
it again appears. It depends also upon the irritable condition of 
the overworked and contracted abductor muscles, practically the 
only group which retains functional power.; thus the spasm, as 
has been stated in describing the severe and painful type of weak 
foot, is greater after the day's use and relaxes somewhat during the 
night. The degree of muscular spasm and rigidity corresponds 
with the intensity of the symptoms, but by no means with the 
depression of the arch or with the duration of the deformity. 

Extreme Types of Weak Foot. 1. Persistent Abduction. In 
one type of deformity the foot is twisted outward and upward. 
It may be everted to such an extent that practically the weight 
is borne upon the heel and the ball of the great toe. In such 
instances the astragalus, although rotated inward upon the 
pronated os calcis, is, of course, not plantar flexed nor is the 
anterior extremity of the os calcis depressed. The entire foot is 
-imply held in an attitude of extreme abduction and dorsal flexion 
by the spasm and contraction of the flexors and abductors, so that 
the le^r most be bent at the knee and inclined forward to bring 
the sole to the ground. Such extreme cases are uncommon. 
They are often the direct result of injury, so-called chronic sprain. 
extreme examples of this class are very common. The foot 
i- simply turned to oik; side (valgus) and the arch appears to be 
depressed because of the attitude, whereas it may be in reality 
exaggerated in depth. 

2. Pes Planus. As has been stated already, and as is well- 
known, there is a type of painless flat-foot sometimes called pes 
planus, in which the flatness of the foot is more noticeable than 
tie- ether components of the deformity that have been described. 
This is probably the result of inherited laxity of ligaments or of 



DISABILITIES AND DEFORMITIES OF THE FOOT. 677 

rhachitis or other form of acquired weakness in early life, so that 
a normal arch was never present. Such a foot controlled by 
normal muscles may be strong and efficient, but it is, nevertheless, 
deformed, and it is doubtful if its possessor ever could attain the 
and elasticity of gait possible under normal conditions. It 
is said, also, that a low arch is normal in certain races, for 
example, the negro, but it is certain that the American negro is 
not exempt from the pain and disability incidental to the broken- 
down foot, whether his arch was originally low or not. 

It is evident, of course, that the breaking down of a properly 
shaped foot, provided with normal ligaments, will be attended 



Fig. 403. 




Weak feet ami alight knock-knees. 



pain and greater disability than of one in which the 
arch was originally low and of which the Ligaments were weak, 

- • is during the progression of the deformity and particu- 
larly in it- early stages tliat such symptoms are most prominent. 
\\ ben tie bones of the arch real upon the ground or when final 
stability has become assured, pain may i ,<l permanent 

imodation to the new conditions may increase the ability of 
the deformed member. Such an outcome mighl be quickly 

iplished in th< iginally flat, while in the other instance 



ORTHOPEDIC SUMGERY. 

the symptoms, although remitting from time to time, might con- 
tinue during the life of the sufferer. 

The abducted foot, in which there, is no depression of the arch, 
and the simple ilat-foot, in which the element of abduction is less 
prominent, represent the two extremes of weak foot. In the 
majority of cases the abduction is combined with a certain laxity 
of the supports of the longitudinal arch as well. 

One may recognize, then, in the weak foot three types of 
deformity : 

1. Valgus, or abduction. 

'2. Yalgoplanus, or abduction and depression. 

3. Planus, or depression. 

This distinction is of some importance from the standpoint of 
prognosis at least in the adolescent and adult cases, as the pros- 
pect of anatomical cure corresponds with the order of classification. 



Weak Foot in Childhood. 

There can be no doubt that in many instances the origin of the 
weak foot may be traced to early childhood. Certainly, deform- 
ities and improper attitudes are very common at this period, and 
it is much more likely that they are ingrown than outgrown. 
Actual pain from the weak foot is rare at this age. The child 
may complain of fatigue and may be weak and awkward, but it 
is usually because of the very evident deformity rather than 
because of symptoms that advice is asked. In these cases, as in 
every case, the habitual attitudes and use of the feet are of the 
first importance. 

Out-toeing and In-toeing as Symptoms of the Weak Foot in 
Childhood. One of the most frequent of the improper postures 
18 that of exaggerated outward rotation of the feet, which is not 
only an ungraceful attitude, but a direct cause of weakness as well. 
The opposite attitude of inward rotation, the so-called " pigeon- 
toed " walk, is most offensive to relatives and friends, and it is 
for correction of the attitude that the child may be brought for 
treatment. The attitude is, in many instances, a sign of the weak 
foot, for on examination the bulging on the inner side, the inward 
rotation of the leg in its relation to the foot, and the depressed 
anli show very plainly that it is the foot and not the attitude 
that requires treatment; in fact, the attitude is, in this class of 
cases, really a safeguard against increasing deformity, and it will 
correct itself when its eause is removed. Particular emphasis is 



DISABILITIES AND DEFORMITIES OF THE FOOT. 679 

laid upon this point, which is very generally overlooked, because 
the routine treatment of the (i pigeon-toes" in these cases might 
be the cause of direct harm. 

Weak Ankles. " Weak ankle" is a term popularly applied 
to the weak foot of childhood, in which the foot is in a position 
of valgus when in use, so that the shoe is worn away on its inner 
side. Weak ankles are very common in very young children 
and are often one of the results of general weakness due to 
defective assimilation. At this age the foot is, in addition, usually 
Pig. !"■'> . but in the valgus or weak ankle of later years 
the arch is often practically normal in outline. 

Fig. 404. 




Congenital flat-foot. Rigid deformity of an extreme type, illustrating the component 
abduction and obliteration of the arch. 



Outgrown Joints. In older children prominent or " out- 
grown" joints often attract the mother's attention ; the internal 
malleoli appear prominent because of the position of valgus, or 
I the turning out of the feel the malleoli may strike 
tother, •• interfere," and thus there may be an actual 
hypertrophy of the projecting bones from local irritation. 

ther type is the long, -lender foot, in which the navicular 
is prominent b of the -train and pressure put upon it by 

mproper attitudes ; it- position is often -down by the point 
of wear in the Leather of the shoe Fig. M)2). 

In the-.v • of childhood, although restriction of voluntary 



680 



ORTHOPEDIC SURGERY. 



and passive motion may be present, there are, as a rule, but little 
local tenderness and muscular spasm, and, as has been said, but 
little actual pain. Thus it differs greatly from the adult type, for 
the reason that the weak foot in childhood has not beeu subjected 
to the strain of constant occupation or to the burden of the in- 
creased weight of the body. There is another important difference 
also ; the foot of the adult is obliged to bear greater strain than 
any other part, and although normal in structure it may be over- 
strained, so that in many or in most instances the weakness of 
the foot may be the only disability. But in childhood, when 
such exciting causes are absent, a weak foot is very often a local 
indication of general weakness and loss of tone. 



Fig. 405. 




Flat-foot ; extreme deformity in childhood. 

Irregular Forms of Weak Feet. Occasionally the apex of 
the inward bulging and deformity is not at the mediodorsal joint, 
but anterior to it in the cuneiform region. Iu such cases the 
internal cuneiform bone may be enlarged and sensitive to pressure. 

Another form is the combination of a plantar flexed toe with a 
depressed arch (Fig. 406). Extreme deformity of this class is 
usually congenital. A milder type is not uncommon. (See 
Hallux Rigidus.) 

Weak Feet and Deformity of the Legs. In childhood weak 
feet are often seen in combination with slight knock-knees (Fig. 
103), although more marked knock-knee usually induces in com- 
pensation the opposite attitude of adduction. (See Knock-knee.) 
Bow-leg in childhood is usually accompanied by slight inward 
rotation of the feet, but in later life there is usually a certain 




DISABILITIES AXD DEFORMITIES OF THE FOOT. 681 

degree of compensatory valgus, although it does not, as a rule, 
cause discomfort. 

General Weakness. The direct effects of the weak and pain- 
ful foot have been described in detail. It must be borne in mind 
that the feet are the foundation of the body, and that an insecure 
foundation affects the entire mechanism. General functional 
weakne-- and awkwardness, the flat chest, round shoulders, or 
other curvatures of the spine, are 
often observed as accompaniments 
or effects of weak feet. Thus, as 
a ride, the systematic treatment 
of any form of postural weakness 
must include the treatment of the 
feet as well. 

Recapitulation. The disability 

and deformity of the weak Or H ammeMoe flat-foot. (Nicoladoni.) 

so-called flat-foot are caused by 

a disproportion between the strength of the foot and the weight 

and -train to which it is subjected. 

The foot may be weakened by injury or disease; it may be 
overburdened by the body weight, or overstrained by laborious 
occupation, or the broken-down foot may be simply one indica- 
tion of general bodily weakness. It is unnecessary to enumerate 
all the various factors that singly or combined lead to this dis- 
ability. It may be stated, however, that the weak foot is in 
many <>r most instances the only disability that demands treat- 
ment. Its most constant predisposing causes are the direct injury 
caused by improper shoes and the mechanical disadvantages to 
which it is subjected by the assumption of improper attitudes. 
All weak or flat feet are mechanically weak, but all weak 
are by no means painful feet. Pain, the symptom of over- 
in or injury, boars no definite relation to the degree of 
deformity. 

In certain instances exaggeration of the arch may be combined 
with persistent abduction of the foot; in others, the flattening of 
the arch may be the most noticeable deformity, but in most cases 
the two are combined in varying degree. And as each deformity 
is an evidence of weakness, it seems hardly necessary to make a 
radical distinction between the two, except as regards prognosis. 
1 r theabdueted fool in which the arch is intact ie almost always 
an acquired deformity of Bhorl duration, whereas in the case of 
the foot in which the arch is obliterated the deformity usually 



682 



ORTHOPEDIC SURGERY. 



dates from early childhood, and it is, therefore, far less amenable 
to treatment as far as perfect cure is concerned. 

Treatment. The principles of the treatment which leads to 
the permanent cure of the weak and deformed foot are very 
simple, l>ut the application varies somewhat according to the 
grade and duration of the deformity. The object of treatment is 
to so change the weak foot that it may conform not only in 
contour but in habitual attitudes and in power of voluntary 
motion to those of the normal foot, because complete cure is 
impossible unless normal function is regained. The first step 
must be, therefore, to make passive motion free and painless to 
the normal limit. In other words, the obstructions to the motion 
of the machine must be removed before the power can be properly 
applied ; for the increase of muscular strength and ability, on 
which ultimate cure depends, is not possible while motion is 
restrained by deformity or by pain or by adhesions or contrac- 
tions. 

The weak foot, because of inefficient ligaments and muscles 
unable to hold itself in proper position, must be supported, in 
many instances, until regenerative changes have taken place 
in its structure. Such support is necessary to retain the joints in 
normal position, and to hold the weight in proper relation to the 
foot, otherwise normal function is impossible. When these essen- 
tials are provided the patient may cure himself by the proper 
functional use of the foot and by the avoidance of attitudes 
that place it at a disadvantage. 

It may be well to describe, first, the treatment that must be 
applied to all classes of weak foot in which a cure is to be 
attempted, and which by itself is sufficient in the milder types, 
before calling attention to the modifications that may be necessary 
in special cases. 

The Shoe. In practically all cases it will be necessary to pro- 
vide the patient with a proper shoe, for the shoe is usually the 
direct cause of the minor deformities, and indirectly, in many 
instances, of more serious disability. Indeed, most of the 
deformities and disabilities of the foot are incidental to civiliza- 
tion and are, therefore, confined to the shoe-wearing people. The 
direct effect of the ordinary shoe is to lessen the area and the 
adjustability of the fulcrum by cramping the toes together. Indi- 
rectly it causes deformities — corns, bunions, and the like — which 
serve to make active movement or leverage painful, so that it is 
replaced by the passive attitude. 



DISABILITIES AXD DEFORMITIES OF THE FOOT 683 



Fig. 407. 



The proper shoe should contain sufficient space for the inde- 
pendent movements of the toes. This motion is illustrated in the 
ivalk of the barefoot child. As the weight falls on the foot the 

s spread, and as the body is raised on the foot they contract. 
The important leverage action of the great toe and the support 
afforded by it to the arch of the foot have been mentioned already. 
The shape of the sole should corre- 
spond to the shape of the foot and the 
heel should be broad and low (Fig. 
4' '7 i. It will be noted that the front 
of the sole of the shoe in the figure 
407 appears to be pointed slightly 
inward. Such a shoe aids in prevent- 
in- abduction, and it is therefore an 
important adjunct to the brace in re- 
straining deformity. 

Raising the Inner Border of the Shoe. 
A simple expedient in the treatment 
<>f the weak foot and an aid in balan- 
<iiiLr it properly is to make the inner 
border of the sole and heel of the shoe 
slightly thicker in order to throw the 
weight toward the outer side of the 
f<>ot. This is of special importance 
in the treatment of the slighter degrees 
of what ifl known as weak ankle, and 
it i- always of service in the treatment 
of any grade of weak foot. 

Attitudes. The patient's attention 
i- then called to the three elements of 
kness. He is instructed to guard 
ajufl Fig. 391 ) by throwing 
tie- weight on tie- outer side of the foot 
2 and to guard against ab- 
duction by holding tie- feet parallel with one another in walking 
374 : the significance of the bulging on the inner side of 
th«- font i- pointed out to him. and how this may be prevented by 
the avoidance of tie- postures just indicated, and by aiding the 
arch by tie- power of the great toe. The importance of leverage 
i- shown him, that he must try to press down tie* sole of the 

-ho.- with hi- toes, ami employ tie- active lift of the calf QlUSCleS 

by fully extending the leg and raising the body on tie- foot from 




The proper relation of the sole to 
the shape of the foot. A, outline of 
sole: B, outline of foot; C, imprint 
of foot. 



68 I ORTHOPEDIC SURGERY. 

time to time (Fig. ;>74). Finally, he must avoid long continuance 
in one position, especially the passive posture, which, even in the 
normal subject, simulates the attitude and deformity of weak foot. 
I ii short, lie must be instructed in the mechanics of the foot and 
taught how the weak foot may be protected as well as strengthened. 

Exercises. It is important, also, to demonstrate to the patient 
the normal range of motion of the foot, motion which, if 
restricted, must be regained by voluntary and passive exercises. 
Voluntary exercise should be devoted to strengthening the ad- 
ductors and plantar flexors ; thus the foot should be adducted 
and supinated then dorsiflexed in the attitude of slight adduction 
(Fig. 378) over and over again at every opportunity. Tip-toe 
exercises are especially useful ; the patient, placing the feet in 
the attitude of moderate inward rotation, raises the body on the 
toes to the extreme limit, the limbs being fully extended at the 
knees, then sinking slowly, resting the weight on the outer bor- 
ders of the feet, in the attitude of marked varus, twenty to one 
hundred times. This exercise is somewhat difficult, and it cannot 
be carried out properly if there is any limitation of motion or 
sensitiveness at the mediotarsal joints. The best of all exercises 
is, however, the proper walk, in which the leverage power of 
the foot is employed, and in which it passes through the proper 
alternation of postures (Fig. 374). Treatment by massage and 
special gymnastic exercises is, of course, of benefit if the patient 
can command it, although by no means essential to the cure. 

Support. In many instances the simple treatment that has 
been outlined is all that is required, and the symptoms of tire 
and strain are quickly relieved, but in the majority of cases the 
patient is not able to prevent deformity voluntarily ; consequently 
a -npport is necessary to hold the foot in proper position and to 
relieve discomfort. It is usually necessary in the treatment of the 
weak foot of childhood because one cannot command the aid of 
the patient 

In selecting a support for the weak foot the nature of the 
deformity that is to be prevented should be borne in mind; that 
the acquired flat-foot, for example, is not a direct breaking down 
of the arch, as is usually taught, but a lateral deviation and sink- 
ing — a compound deformity, as has been already described (Fig. 
393). Thus a brace to be efficient must hold the foot laterally 
a- well as support the arch. But it must not prevent the normal 
motions of the foot, and thus interfere with the increase of 
muscular Btrength and ability, on which ultimate cure depends. 






DISABILITIES AND DEFORMITIES OF THE FOOT. 685 

The supports that have been ordinarily used for flat-foot do 
uot fulfil the conditions ; the pads and springs placed beneath the 
arch are intended to support it by direct pressure without regard 
to the valgus or the abduction ; they are usually ill-fitting, and 
are often of such length and shape as to splint the foot and thus 
to restrict its motion. Leg braces which control the valgus do 
not often hold the foot accurately, and their weight and unsight- 
Liness are fatal objections to their use, especially so in the early 

Fig. 408. 




The attitude in which the plaster cast should he taken. In the reproduction the chair 
upon which the foot is resting has been removed. This attitude is important, because in it 
the foot assumes the best possible contour. If the loot is simply pressed downward into the 
plaster cream, the ordinary method of making the model, the shape will be found to bejiuite 
different from that taken in the manner illustrated. 

in which prevention of subsequent deformity is of such 
importance 

A brace should aever be applied to a deformed and rigid foot 
because it cannot adapt itself to tin; support; the spasm and 
rigidity must be first relieved by preliminary treatment, that will 
be described in the consideration of this class of cases. 

The Construction of the Brace. To properly construct a brace 
to nH-'-r these conditions, it is necessary to provide the mechanic 
with a plaster cast of tin- foot, taken in tie' attitude in which one 



686 ORTHOPEDIC SURGERY. 

wishes to support it. Such a model may be easily and quickly 
made in the following manner: 

The Plaster Cast. Seat the patient in a chair ; in front of him 
place another chair of equal height; on it lay a thick pad of 
cotton-batting and cover it with a square of cotton-cloth. Put 
about a quart of cold water into a basin and sprinkle plaster of 
Paris on the surface until it does not readily sink to the bottom ; 
then stir. When the mixture is of the consistency of very thick 
cream pour it upon the cloth. The patient's knee is then flexed, 
and the outer side of the foot, previously smeared lightly with 
vaseline, is allowed to sink into the plaster, and, the borders of 
the cloth being raised, the plaster is pressed against the foot 
until rather more than half is covered. The foot should be at a 
right angle with the leg, and the sole should be in the plane 

Fig. 409. 




A, the astragalonavicular joint. The internal flange of the brace should rise well above 
all the prominent bones to a point about half an inch below the malleolus. 



perpendicular to the seat of the chair (Fig. 408). As soon as 
the plaster is hard its upper surface is coated with vaseline, and 
the remainder of the foot is covered with plaster ; the two halves 
are then removed, smeared lightly with vaseline, and bandaged 
together. The interior is dampened with soapsuds, and it is 
then filled witli the plaster cream. In a few moments the plaster 
shell may be removed, and one has a reproduction of the foot, 
which, when properly made, should stand upright without incli- 
nation to one side or the other (Fig. 412). 

In most instances it will be of advantage to deepen in the 
plaster model the inner and outer segments of the arch, in order 
that the arch of the brace may be slightly exaggerated, especially 
at the heel, so that the depression of the anterior extremity of 
the os calcis may be prevented. 



DISABILITIES AXD DEFORMITIES OF THE FOOT. 687 

The Brace. Upon the model the outline of the brace is drawn 
as illustrated in the diagrams. The best sheet steel, 18 to 20 
gauge, cut after the pattern is moulded upon it and tempered, so 
that, as it is applied for the purpose of preventing deformity, it 
may be practically unyielding to the weight of the body. 

It will be noticed that the brace clasps the weak part of the foot 
and holds it together ; the broad internal upright portion (Fig. 
409) covers and protects the astragalonavicular junction, rising 
well above the navicular; the external arm covers the calcaneo- 



FlG. 410. 



Fig. 411. 





C, the great toe-joint ; D, the cen- 
tre of the heel. 



B, the calcaneocuboid junction. The external flange 
extends from the centre of the heel to a point just be- 
hind the base of the fifth metatarsal bone. 

cuboid junction and the outer aspect 
of the foot to a height sufficient to 
hold the foot securely (Fig. 410). The 
sole part provides a firm, comfortable 
support, yet, reaching only from the cen- 
tre of the heel to just behind the ball 
of the trreat toe, it does not restrain the 

normal motions of the foot (Fig. 411). The brace may be nickel- 
plated aud japanned, which makes a smooth finish, or tin-plated, 
or galvanized, which makes a more durable covering. It may be 
ed with leather, or an inner sole may be placed on its upper 
surface ; bat this is not usually necessary. As it is fitted to the 
foot, it finds and hold- its own place in the shoe, so that no attach- 
ment ifl required; thu- it may be changed from one shoe to an- 
other. Not only does it hold the foot laterally and from beneath, 
but there is an clement of suggestiveness in the slight leverage 
action which is very important, and which is the distinctive 
feature of this brace as contrasted with simple sole plates or 

other supports. 

The Positive Action of a Proper Brace. The patient, instructed 
to throw his weight upon the miter side of the foot and wearing 



688 



orthopedic srnvEii v. 



the shoe which has been tilted in the same direction by thicken- 
ing the inner border of the sole and heel, presses down the 
externa] arm and thus lifts the internal flange against the inner 
side of the foot, which is instinctively drawn away from the 
pressure and thus toward the normal contour. He no longer 
everts or turns the feet outward in walking, because this 
causes positive discomfort, and he is not likely to assume the 
passive attitude, because of the suggestive lateral pressure of the 
support. With the foot held in the proper attitude the patient 
may again walk with the proper spring ; thus the brace itself 
becomes a positive aid in the physiological cure. It is important, 
also, that a shoe of proper shape, as shown in the diagram (Fig. 
407) be worn, as it aids the brace by holding the forefoot in a 
slightly adducted attitude. 

Fig. 412. 




A cast marked for the mechanic. In most instances the internal flange is lengthened as 
in this diagram, as compared with Fig. 409, in order to straighten the support so that light 
steel (gauge 20) may be used. (See Fig. 413.) 



The shape of the brace, in general like that of the diagram, is 
modified in certain cases ; for instance, the entire internal aspect 
of the foot may be weak and must be covered by the internal 
flange. In very heavy subjects the sole portion must be made 
larger, although this is a disadvantage, as it lessens the leverage 
action ; other slight modifications may be necessary in special 
cases. If any portion of the rim of the plate causes discomfort, 
the edge may be turned away slightly at the point of pressure by 
a wrench. After a few days the patient no longer notices the 
presence of the brace, and as its presence in the shoe is not 
evident, it may be worn indefinitely. Steel is the lightest and 
strongest, and, on the whole, the most satisfactory material for 
the brace. It will, of course, rust in time, and for this reason 



Fig. 413. 



DISABILITIES AND DEFORMITIES OF THE FOOT. 689 

each patient should be provided with two pairs of braces, in order 
that the rusted pair may be returned to the bracemaker for repairs. 
In hospital practice heavier material is used and the braces are 
plated with tin, which is fairly resistant. 1 

It is usually necessary for from three months to a year or 
Longer, according to the condition of the patient and the strain to 
which the feet are subjected. The brace, properly made and 
adjusted under the proper conditions, causes no more pre>sure 
or discomfort than a well-made shoe, for its principle is quite 
different from that of the ordinary supports that are in common 

to which this objection has 
been made. This brace supports 
the arch primarily by prevent- 
ing abduction, consequently its 
pressure is felt upon the lateral 
aspect "f the foot, a pressure that 
the patient can relieve by im- 
proving his attitude. The brace 
should afford support when neces- 
Bary, and at all times suggest and 
enforce a proper attitude j it is, 
however, but one of the essential 
factors in the general scheme of 
tment The ordinary form of 
brace is made in the Bhape of an 
inn«r sole, as in the diagram I Fig. 
111. A- it supports the sole of 
tie- foot, and by the elevation of 

it- inner border tends to throw the weight more toward the outer 
-id*-; it i- a useful aid in treatment, but, providing no lateral 

Fig. 414. 




The outline of the sole part of the brace. 




The sole plate ordinarily mod In the treatment of weak Boot. After Bradford and Lovett.) 

support, it cannot prevent the inward bulging of the foot, which 
i- the most important element of the deformity. 

In the treatment of children the foot should be moved in all 
. but particularly in dorsal flexion and adduction to the 



"• In many instances there in a rapid improvement in the shape of the foot under treatment, 
and It is often advisable to make a -< n such cases in order that Hie bract may 

conform to the Improved contour. 

H 



690 ORTHOPEDIC SURGERY. 

full limit lit morning and at night, until the child has regained 
the normal muscular power and ability. Special gymnastics and 
massage are always desirable, and they may be necessary in 
certain cases. Bicycling may be cited as one of the best, and 
roller-skating as one of the worst exercises for the weak foot. 
A year is about the time required for a cure of the weak foot in 
childhood, although attention to the shoes and to the attitudes 
must be continued indefinitely. 

The Rigid Weak Foot. 

One may now contrast with the mild types of weakness that 
have been described the cases of extreme deformity in which 
the symptoms are disabling and in which the foot is rigidly held 
in the deformed position by muscular spasm and by secondary 
changes in its structure. Such cases, often considered hopeless 
as regards a cure or even relief, are in reality the most satisfac- 
tory from the remedial standpoint, and in no other type of pain- 
ful deformity can so much be accomplished by rational treatment 
as in this class. The deformity must be considered as a disloca- 
tion in which the astragalus has slipped downward and inward 
from off the os calcis, which, in turn, is tipped downward and 
inward and into a position of valgus. The remainder of the 
foot is turned outward, so that the relation of the leg and the 
forefoot is entirely changed ; in fact, the forefoot is almost 
entirely disused (Fig. 405). 

Corresponding to the duration of the disability, one finds 
accommodative changes in the soft parts and in the bones, but 
such changes are by no means as marked as those recorded in the 
reports of autopsies which have been made in cases of advanced 
and irremediable deformity. In fact, by far the greater number of 
patients are young adults in whom the extreme deformity is of com- 
paratively short duration, and in whom complete cure is possible. 

In the treatment of such a condition one must first reduce the 
dislocation and overcome the obstacles that contracted muscles and 
Ligaments may offer to free and normal motion ; then rest must 
be assured to the injured and congested parts in order to relieve 
the patient from the pain from which he has suffered so long. 

Forcible Overcorrection. By far the most effective treatment is 
forcible overcorrection of the deformity, under anaesthesia. When 
the patient is under the influence of the anaesthetic the muscular 
spasm relaxes, and it will be seen that this accounts for about 



DISABILITIES AND deformities of the FOOT. 691 

half of the restriction of motion, the remainder being eansed by the 
adaptive changes that have been mentioned. The object of the 
operation is to overcome the residual obstruction, and to assure 
the patient against a relapse, by fixing the foot for a sufficient 
time in the position of extreme adduction and supination, the 
attitude directly opposed to that which has become habitual. 

This is the object of forcible overcorrection as the first step in 
the systematic repair of the disabled mechanism ; its principle 
most not be confounded with forcible correction carried out with 
the object of simply remoulding the arch of the foot, or in which 
the simple correction of the deformity is the object in view. 

( me first extends the foot forcibly, then flexes it to the normal 
limit, then abducts and adducts, the different motions being 



Fig. 415. 



Fig. 416. 




The deformed foot before operation. A, the 
projection of the displaced astragalus and navic- 
ular; B. the Inner malleolus; C, the medio- 
tarsal joint, showing the outward displacement 
before, the inward rotation h point. 




The ovcrcorrected foot, showing the re- 
versal of the lines of displacement. (See 
Fig. 417.) 



carried out over and over until the rigid foot has become perfectly 
flexible In cases <>f Long standing it is often aecessary to draw 
i the end of the table, so thai the foot may be taken 
n the knees, in order to supply th<' required force by the 
I i i i — forcible manipulation is accompanied by the 
audible breaking of adhesions, and in favorable cases by complete 
of the deformity. In certain instances it will be neces- 
sary to dh i'l<- the tendo Achillis, when, for example, the range of 
I by resistant accommodative shortening of 
vrhen there has been very -jr<-A\ pain and tender- 
ir-al joint, and it is desired to remove the strain 



i ; ! i '2 OR THOPEDIC SURGER Y. 

of leverage completely ; traumatic cases come especially under this 
head. Tenotomy has one great advantage : it necessitates longer 
fixation in the plaster bandage, and gives the patient the benefit 
of rest, and the opportunity for prolonged after-treatment. When 
the passive range of motion has been regained, the foot is turned 
downward, then inward and upward into the position of extreme 
varus. By this manipulation the os calcis is drawn under the 
astragalus and thrown into the supinated position, and the 
scaphoid is flexed about and under the head of the astragalus, 
which is then lifted to the limit of normal flexion. The attempt 
is always made to bring the extreme outer border of the inverted 
foot up to a right angle with the leg, which is the limit of normal 
flexion in this attitude. The foot, thickly padded with cotton, 
especially about the toes, is then fixed in this posture of club-foot 
by a firm plaster-of -Paris bandage extending to the knee (Fig. 407). 
Surprisingly little discomfort, considering the force that it is some- 
times necessary to apply, is experienced after the operation. The 
familiar and often intense pain, from which the patient has suffered 
so long, is entirely relieved by the correction of the deformity; 
there is often a sense of tension about the outer side of the ankle 
and dorsum of the foot, but this is not, as a rule, of long duration. 

Functional Use in the Overcorrected Attitude. As soon as pos- 
sible, often on the following day, the patient is encouraged to 
stand and walk, bearing his weight on the foot. Walking serves 
two purposes : to still further overcorrect the deformity, and to 
accustom the patient to a posture entirely different from that so 
long assumed. Meanwhile the contracted tissues on the outer 
side become thoroughly overstretched; the weakened ligaments 
and muscles on the inner side are relaxed, and the local irritation 
rapidly subsides under the rest from the constant injury to which 
the foot has been subjected. 

The patient is not confined to the bed or house, although if 
both feet are in plaster bandages crutches are, of course, neces- 
sary. The time that the feet should remain in the overcorrected 
position depends upon the duration of the deformity and the 
severity of the symptoms, or from two to six weeks, the usual 
time being about four weeks. At the end of about three weeks, 
or whenever the patient can support the weight on the plaster 
bandage, without a sensation of discomfort, it is removed; the 
foot is placed in the normal attitude and a cast is taken for the 
brace (Fig. 408). Immediately after, the foot is returned to 
the club-foot position and the plaster bandage is reapplied. 



DISABILITIES AND DEFORMITIES OF THE Fool'. 693 



. the brace is ready the plaster bandage is finally removed; 
2 od position, and in many instances the aroh 
i in depth. For the first few days prolonged soak- 
g d hot water or the use of the hot-air hath, with subsequent 
ssag als during the day, will be found useful in over- 

coming the swelling and Local tenderness that may remain. It is 
alwaj usted that a new -hoc of the Waukenphast pattern 
shall be obtained, the sole and heel of which arc raised a quarter 
of an inch on the inner border 

i in the balancing of the n7 - 

•. The brace is then 
applied, and the patient is 
never allow* d to walk with- 
out it- support When the 
is removed at night 
structod to turn the 
in and t«> bear the weight on 
the out r Bide of the root until 
it has 1 it- strength ; in 

deformity is 
■ d t<» recur. 
Systematic Manipulation. 
treatment i- 
then begun by th.- Burg 
and the patient, th.- first 
essential being th.- attainment 
and painless passive 
in all directions, 
which have 
. so lon§ [ned by 

ined 
without *-fTort, and during this 

tment must be carried "ut by the surgeon him- 

bJa friends a cure is out of 

-■ "ii. At day tin- full range of motion must 

the normal limit. Three motions— abduction, 

>n, and • -an- usually fr< <• and painless j but the 

4 adduction, i- almost invariably resisted by the 

quality of muscular rigidity that was present before the 

By far tin- most effective method of overcoming this 

The patient being seated in 

• uid- before him. Let >• luppoae 




The for at-fbot The 



694 ORTHOPEDIC SURGER Y. 

that the left foot is to be adducted or, as the patients express it, 
twisted. The surgeon places the foot between his knees ; his left 
hand encircles the heel, the fingers grasping the projecting os calcis 
and tendo Achillis; the base of the palm lies against the medio- 
tarsal joint on the inner and inferior aspect of the foot ; the right 
hand grasps the outer side of the forefoot and toes ; then, by- 
steady pressure of the thigh muscles, the forefoot is forced down- 
ward and inward (adducted and supinated) (Fig. 338) over the 
fulcrum formed by the projecting palm, which lies upon the left 
knee, the fingers holding the heel steadily in place. This inward 
twisting is at first resisted by a mixed voluntary and involuntary 
muscular spasm, which gradually gives way under steady press- 
ure. When the limit of adduction has been reached, the foot 
is held firmly until all pain has subsided ; then the patient is 
instructed to attempt voluntary movements while the foot is 
guided by the hands ; in other words, the patient attempts to 
adduct the foot while the surgeon supplies the power, which in 
all cases of this type has been completely lost. This passive 
manipulation to the extreme limit of normal adduction, plantar 
and dorsal flexion, is continued from day to day until there is no 
longer a sensation of pain or tension. For as long as there is the 
slightest spasm or painful restriction of passive motion, the vol- 
untary assumption of proper attitudes is checked, and until this 
power is regained there is danger of relapse. During active 
treatment, therefore, the patient, by means of massage and active 
and passive exercises, must constantly work to one end, namely, 
to regain the lost power of voluntary adduction. 

The time necessary to rest the feet, to overcome the local 
irritation and muscular spasm, to regain, in part at least, the 
range of passive motion, and to place the patient in the same 
position, as regards a cure, as in the milder types of defor- 
mity, is from three to six weeks. Usually the patients are told 
that a month will be necessary, and that at the end of that time 
they may return to work, free from pain and from the danger of 
relapse, and that the feet will constantly grow stronger under 
the work which was before too great for their strength. The 
time necessary to re-educate the adductor muscles in their proper 
function depends, in great degree, upon the intelligence and per- 
sistence of the patient. Although in after-treatment massage and 
special exercises are of benefit, the essentials are very simple ; 
they are an effective brace, a proper shoe, the passive manip- 
ulation that has been described until its object has been attained, 



DISABILITIES AND DEFORMITIES OF THE FOOT, 696 

and the proper walk, the best and easiest of exercises. Finally, 
one must force into the patient's understanding the method of 

Sting the weak foot by the alternation of strain, and by 
proper postal 

Other Varieties of Rig^d Weak Foot. Tin foot which is 
<\\> <\ in the abducted position without depression of the longi- 
tudinal arch 18 -imply one variety of the rigid weak foot, which 

should he treated in the same manner. It may be stated, also, 
that a very large proportion of the so-called ehronie sprains of 

the ankle are of this type, and that the disability will yield very 
readily t-> treatment, conducted for the purpose of restoring- 
impaired function, in the manner that has been indicated. 

In certain instances the apex of the deformity lies in front 
of tin- astragalonavicular joint, in the naviculoouneiform region, 
and the interna] cuneiform hone may he enlarged and sensitive 
bo pressure. Such cases should he treated on the same general 
principles a- the ordinary variety. 

In rare instances marked depression of the arch is accompanied 

by flexion contraction of the great toe, as if the result of an 

attempt to support the weak arch. This was described by 

adoni as hammer-toe flat-foot (Fig. 106). The association 

of painful great toe (hallux rigidus) and weak foot is mentioned 

lere pagi 7 v . 

rh< ■]•'■ are other cases in which the deformity of flat-foot is 

licated by rheumatoid arthritis or chronic rheumatism, of 

which the evidence is seen in various joints, hut in which the 

pain and discomfort seem to he concentrated in the feet, which 

itely >tiff and deformed. In Buch cases one can hardly 

• a complete cure; hut although the function of Leverage 

ined, -till one may hope, by overcoming the 
deformity, to bold the weight <»f the body in it- proper relation 

to tip ■ that the pain of a progressive dislocation may not 

the pain of disease. In a Dumber of instances 

•"rre.-tion has hem employed by the writer in oases of 

and in all the improvement in the general condition. 

quently in the n-i~tan<-.' to the disease, after the relief of 

the local pain and discomfort, ha- been very great 

••hi-' - of (•>,.,, the mild ;md t)l< -.(;,• 

rind- every grade *,f deformity. All eases in which th< 
marl-' ' tenderness, and swelling require 

instances limply rest from functional 
: with massage; in others, rest in a plaster bandage 



696 ORTHOPEDIC SURGEIi V. 

in tin' adducted position. In the milder and ordinary class of 
cases the use of a brace and shoe will alone relieve spasm and 
pain, and the range of motion can usually be regained by 
manipulation, passive motion, and by the proper use of the foot. 

Occasionally, even in childhood, one may encounter marked 
limitation of normal motion, particularly in dorsal flexion, not 
due to pain and muscular spasm, but to actual shortening of the 
muscle. This may be the accommodative shortening that is 
characteristic of long-standing deformity; in other instances it 
would appear to be the result of a slight and unnoticed neuritis 
or anterior poliomyelitis, which has resulted in muscular inequal- 
ity. If the contraction does not yield readily to manipulation or 
to mechanical stretching, forcible correction, and, if necessary, 
tenotomy should be employed in the manner already described ; 
for whatever may be the theory of its causation it is again 
emphasized that obstruction to motion in any direction must be 
overcome before a complete cure is possible. 

Adjuncts in Treatment. It must be apparent that in many 
instances the cure of the weak foot is out of the question, either 
because of the want of energy or opportunity on the part of the 
patient, or because of the local or general conditions, types 
familiar in out-patient practice. 

The Thomas Treatment. In such cases raising and strengthen- 
ing the inner side of the shoe by the wedge-shaped leather sole, 
as used by Thomas, splints the painful foot and aids in relieving 
the strain. 

Plaster Strapping. If the symptoms are more acute the 
adhesive plaster strapping, as advocated by Cottrell and Gibney 
for the treatment of sprains, is often of service, although it is 
applied in a different manner, and with a different object in 
view. One end of a strip of adhesive plaster, about fifteen inches 
long and three inches wide, is applied to the outer side of the 
ankle just below the external malleolus ; the foot is then adducted 
as far as possible, and the band is drawn tightly beneath the 
sole and up the inner side of the arch and leg, and is stayed in 
tli is position by one or two plaster strips about the calf. Narrow 
plaster straps are then applied about the arch and ankle, in the 
figure-of-eight manner, and a bandage is applied. The manner of 
application, although not the attitude, is shown in Fig. 26b 1 . The 
object of the dressing is to aid in holding the foot in the proper 
position by the support and suggestiveness of the plaster, and to 
provide the firm compression about the arch that is always agree- 



DISABILITIES AXD DEFORMITIES OF THE FOOT. 697 

able to the sufferer from weak foot. This treatment, combined 
with the built-up shoe, is often very effective in overcoming the 
acute and disabling symptoms of the weak and injured foot, which 
arc. as has been stated, often the result of extra strain or injury ; in 
other words, a sprain of a weak foot. Consequently, when these 
symptoms are relieved, the patient who has become habituated 
to the weakness and deformity, considers himself cured. By per- 
sistent manipulation and subsequent support with the adhesive 
plaster one may overcome the resistance to deformity in the 
majority of cases. Forcible correction under anaesthesia is, how- 
ever, preferable. 

Operative Treatment. The various cutting operations for the 
relief of flat-foot do not call for extended comment. The typical 
operation, the removal of a wedge from the astragalonavicular 
region, aims simply at removal of the deformity. It should be 
restricted to those cases in which the adaptive changes are so 
marked that functional cure is impossible. 

Arthrodesis. To fix the foot at the astragalonavicular articula- 
tion in the attitude of slight adduction is a useful aid in restrain- 
ing deformity of the valgus type in paralytic disability, and it 
may be of service in the treatment of certain cases of weak foot 
of a slighter grade in the class of patients not amenable to ordi- 
nary treatment. 

The operation of advancement of the posterior extremity of the 
os calcis, as proposed by Gleich, in order that it may be placed 
in relation to the leg somewhat like that of a Pirogoff amputa- 
tion, offers little hope of ultimate cure. For since the disability 
is not due to primary depression of the arch, it can hardly be 
eared by exairirerating its depth in this manner. Supramalleolar 
osteotomy, in which the bones of the leg are divided above the 
ankle, and the distal extremity turned inward, with the aim of 
directing the weight toward the outer border of the foot, has been 
advocated by Trendelenburg. In practice the operation is by no 
UK-ails always successful, while the bow-leg deformity that results, 
if the object is attained, is an unfortunate accompaniment of the 
treatment. It may be mentioned in this connection that fracture 
at tlw ankle-joint, followed by faulty union in a position of valgus, 
is a form of traumatic flat-foot that may !><• cured by this opera- 
tion, in operative treatment the element of rest, necessary for 
ks or months, must be taken into consideration, as explaining 
in part the immediate favorable effect of whatever procedure is 
adopted. 



ORTHOPEDIC SURGERY. 



In conclusion, the following points are again emphasized: 
Flat-foot in its surgical sense is a compound deformity, in which 
the abnormal relation between the foot and the leg, causing the 
improper distribution of the weight and the strain and disuse of 
normal function, is of vastly greater importance than the depres- 
sion of the arch, which has given the name to the disability. 

The weak and deformed foot can be cured, but only by the 
application of the simple principles that any mechanic would 
apply to a disabled machine whose structure and use were known 
to him. In other words, there can be no permanent cure of weak- 
ness and deformity unless normal function is regained, or effective 
treatment unless it has this end in view. 

The term weak foot has this advantage over others that imply 
deformity, in that it may be properly applied to the earliest in- 
dications of disability. Once weakness is recognized, its causes 
may be analyzed and appreciated at their proper value. Flat-foot 
is a particularly objectionable and misleading term, and it should 
be discarded or at least used only to describe those cases to which 
it can properly be applied. 



CHAPTEE XXI. 

DISABILITIES AND DEFORMITIES OF THE FOOT (Continued). 
The Hollow or Contracted Foot. 

Synonyms. Xon-deforming club-foot, talipes arcuatus, talipes 
plantaris, talipes eavus. 

The depth of the arch and the corresponding area of the bear- 
ing surface of the sole of the foot vary greatly in different 
individuals, and, although marked differences in appearance and 
function are possible within a normal range, yet, as a rule, the 
low arch is characterized by a certain relaxation and weakness of 
structure, while the exaggerated arch implies a corresponding 
contraction and loss of normal elasticity. 

The hollow or contracted foot may be divided into two classes 
— the primary and the secondary. In the first class the simple 
exaggeration of the arch (talipes arcuatus) is the only change 
from the normal condition. In the second the high arch is com- 
bined with a certain limitation of the range of dorsal flexion at 
the ankle-joint (talipes plantaris — Fisher). 

Etiology. The simple hollow foot may be an inherited pecu- 
liarity. The depth of the arch may be exaggerated by the 
habitual use of high heels (postural equinus), or by excessive use 
of the calf muscles, as by professional dancers. 

The secondary variety, in which the hollow foot is combined 
with Blight equinus, is usually acquired, and in the majority of cases 
it- origin may be traced to a mild and transient form of anterior 
poliomyelitis or neuritis in early childhood. This causes tem- 
porary weakness of the anterior group of muscles of the leg, and 
tli u- a slight toe-drop, followed by secondary contraction of the 
tissues of the Bole and of the muscles of the calf. In the history 
of many of these patients it will appear that after recovery from 
scarlatina or other contagions or infection- disease the child 
seemed weak or awkward. These symptoms became less marked 
or practically disappeared ; yet a trace remained, although not 
of sufficient importance to call for treatment, until adolescence or 
adult life, when the greater -train and weight put upon the feet 



00 



o I! TIIOPEDIC S URGER Y. 



brought to light the latent disability. The affection may un- 
doubtedly develop in later years as the result of neuritis, or of 
gout or rheumatism. It may be caused by a sprain or fracture 
of the ankle, and it may be a result of habitual posture to com- 
pensate for a leg shortened by injury or disease. 

The exaggerated arch which is a part of a more important 
deformity, as of equinovarus or calcaneus, or that which is simply 
a part of the general deformity caused by diseases of the nervous 
apparatus, does not belong to the class of disability under con- 
sideration. 

Fig. 418. 




The contracted foot of slight degree. 



Symptoms. The simple hollow foot often exists without 
symptoms ; in fact, it is often considered as a particularly well- 
formed foot rather than a deformity. The usual complaint in 
these cases is that one is unable to buy comfortable shoes because 
the ordinary shoe does not support the arch, or because the upper 
Leather exerts uncomfortable pressure on the dorsum of the foot. 
The convexity of the dorsum, of course, corresponds to the depth 
of the arch, and in many instances the cuneiform bones project 
sharply beneath the skin, and painful pressure points or even 
inflamed bursa- in this locality may cause discomfort. 



DISABILITIES AXD DEFORM 1 1 IES OF THE FOOT. 701 

111 the well-marked cases in which the weight is borne entirely 
on the heel and the front of the foot, calluses and corns usually 
form at the centre of the heel and beneath the heads of the 
metatarsal bones. The patient may complain of neuralgic pain 
about the great toe, the metatarsal arch, or in the sole of the foot. 
The gait is often ungraceful, as the patient walks heavily upon 
the heels with the feet turned outward. In such cases " the 
ankles may he weak and turn easily." In the more advanced 
cases of this type the foot may assume the position of valgus 
wl icn weight is borne, so that the more noticeable symptoms are 

- of the weak foot or so-called flat-foot, even though the 
deptli of the arch is exaggerated. 

Fig. 419. 




■ oted foot, marked. 



[traded font, of the more severe grade, is almost always 
accompanied by a certain limitation of dorsal flexion; and as the 

n i 1 j u r of the plantar fascia is often more marked at its inner 
border, a slight inversion of the forefoot or varus may be presenl 

When t!i»- exaggerated arch i- combined with Limitation of 

flexion the deformity i- usually greater. This limitation 

may be very -li'_ r ht, or it may be well marked ; and a Blight 

permanent equinua even may be present, but so slight as 

- ii'.T. a- a nile, attract attention. 



702 ORTHOPEDIC SURGERY. 

This type of the contracted foot was first clearly described by 
Shaffer in L885 under the title of " non-deforming club-foot," 1 
and later by Fisher, of London, as " talipes plantaris." 

The symptoms are similar to those of the simple hollow foot, 
but they are almost always more marked. The gait is awkward 
and jarring, the feet being turned outward to an exaggerated 
degree. The patient is easily fatigued, and often complains of the 
weakness about the ankle and inner side of the arch, characteristic 
of the weak foot, and of sensations of tire and strain in the calf 
of the leg. The discomfort from corns, the pain referred to the 
metatarsal region, the great toe, and to the sole of the foot have 
been described already. 

( )n examination the exaggeration of the arch is evident, and 
an imprint of the sole shows that the weight is borne entirely on 
the heel and on the heads of the metatarsal bones, which may be 
very prominent beneath the thickened skin, as if the subcutaneous 
pad of fat had been absorbed. The anterior metatarsal arch is 
often obliterated, and the toes are usually habitually dorsiflexed 
at the first phalanges, the permanent flexion, with the resulting 
pressure against the leather of the shoe being indicated by a row 
of corns upon their dorsal surfaces (Fig. 419). 

The contracted plantar fascia may be demonstrated by forcible 
dorsal flexion of the foot, when the tense bands, in many instances 
very sensitive to pressure, may be felt beneath the skin. 

On testing the motion of the foot, the limitation of dorsal 
flexion, both of the voluntary and the passive range, will be 
evident. In voluntary flexion the toes are drawn up and the 
tendons are plainly seen on the dorsum, showing the effort made 
by the accessory muscles to overcome the abnormal resistance. 

The limitation of dorsal flexion may be demonstrated in the 
manner suggested by Shaffer, by asking the patient to flex the 
feet while standing erect with the back to the wall, when, in spite 
of the effort made, " the feet remain glued to the floor." 

Treatment. In the ordinary form of contracted foot, as has 
been stated, the disability is much more marked than the defor- 
mity : and the disability is due to secondary changes in the struc- 
ture of the foot, by which its elasticity is impaired. If this can 
be restored in some degree permanent relief will follow. If the 
hid pic hollow foot (cavus), or the secondary type (plantaris), 
were discovered in early childhood, massage and methodical 

1 New York Medical Record, May 23, 1885. 



DISABILITIES AND DEFORMITIES OF THE FOOT. 703 

stretching would, in all probability, be sufficient to relieve the 
contractions \ but, as a rule, no symptoms are noticed until later 
life. Even then, especially in the simple form, they are often 
slight and may be relieved by a shoe with a broad heel and a high 
(Spanish) arch or by a foot plate that equalizes the pressure on 
the -oh'. 

In the more advanced cases of the milder type methodical 
forcible manual stretching of the parts may elongate the tissues 
sufficiently to relieve the symptoms. The Shaffer 1 " traction 
shoe" may be used with advantage for the same purpose. In 
the more resistant cases, however, division of the contracted parts 
and forcible correction of deformity is indicated. 

Operative Treatment. The patient having been anaesthetized, 
a tenotomy knife is introduced beueath the skin to the inner side 
of the central band of fascia. This is divided by a saw T ing 
motion, and if on forced dorsal flexion other tense bands appear 
they are divided also. Forcible massage, with the aim of making 
the foot flexible and reducing the depth of the arch, is then 
employed. If sufficient force cannot be employed by the hands, 
the Thomas wrench may be used as in the treatment of club-foot ; 
the object being to elongate the foot, to remove the contraction, 
and thus by increasing the area of bearing surface to relieve the 
painful pressure on the heads of the metatarsal bones. If the 
contraction of the tendo Achillis cannot be overcome by forcible 
manipulation it may be divided. The foot, held in an attitude 
of dorsal flexion, is then fixed in a well-fitting plaster bandage, a 
thin board, shaped to the foot, having been incorporated in the 
bandage, in order that firm and even pressure may be exerted 
upon tli" sole. A- soon a- possible, often on the following day, 
the patient i- encouraged to walk about, in order that the pressure 
of the body weight may be utilized to flatten the foot still more, 
while it- tissues are in a yielding condition. 

The bandage may be worn for Bis weeks, or, if the tendo 
Achillis In- been divided, until its repair is complete. A well- 
fitting -hoc should be worn, and methodical massage and stretching 
of tie- tissues should !>'• continued a- long a- the tendency t<> 
deformity remains. 

By this treatment the symptoms may be relieved, and iu 
many instances a return to the normal shape and function can 
be assun 

k Medical Journsi 



7ii | ORTHOPEDIC SURGERY. 

Weakness of the Anterior Metatarsal Arch. 

Anterior Metatarsalgia and Morton's Neuralgia. A pecu- 
liar spasmodic pain about the fourth toe was described by Mortou, 
of Philadelphia, long before its predisposing and exciting causes 
were understood. For this reason a description of the symptoms 
may with advantage precede a consideration of the weakness of 
which they are usually the result. 

Typical cases of Morton's 1 painful affection of the foot are 
characterized by a sudden cramp-like pain in the region of the 
fourth metatarsophalangeal articulation. 

The pain may begin as a burning sensation beneath the toe, as 
a numb or tingling feeling, as a sudden cramp, or as a peculiar 
feeling of discomfort about the articulation that increases in 
severity until it becomes almost unbearable. At first the pain is 
confined to the neighborhood of the affected joint, but unless it 
is relieved it radiates to the extremity of the toe, to the dorsum 
of the foot, or up the leg. In many instances the onset of the 
pain is preceded by the sensation of something moving or slipping 
in the foot ; in some cases the pain may be induced by sudden 
movements, missteps, or long standing, and in practically all 
the cases the pain is felt only when the shoes are worn. The 
frequency of the recurrent cramp varies ; in some cases it is felt 
only at infrequent intervals ; in others it practically disables the 
patient. When the cramp habit has been acquired, very slight 
causes may induce the pain, for example, a thin-soled shoe, a hot 
pavement, " the sticking of the sock to the foot," and the like, 
but, as has been stated, except in the very advanced and chronic 
cases, the pain is never felt except when the shoe is worn. 

To relieve the pain the patient removes the shoe, rubs and 
compresses the front of the foot, flexes and extends the toes, and 
the like. After the cramp is relieved a sensation of soreness 
remains, and occasionally slight swelling may appear, but in 
most instances there are no external signs, although the affected 
articulation is usually sensitive to deep pressure at all times. 

The more distinctive term, anterior metatarsalgia, a term sug- 
gested by Poulosson, of Lyons, in 1889, may be employed to 
include Morton's neuralgia, and similar symptoms of pain and 
di -comfort about the anterior metatarsal arch. For in many 
instances the cramp-like pain is referred to other points, for 

1 T. G. Morton. American Journal of the Medical Sciences, August, 1876. 






DISABILITIES AND DEFORMITIES OF THE FOOT. 705 

example, to several adjoining joints, or the discomfort caused 
apparently by direct pressure on the bones of the weakened arch 
may be more troublesome than the irregular attacks of neuralgic 
pain. 

Etiology and Pathology. In 78 cases of anterior meta- 
tarsalgia in which the location of the pain was noted, it was 
referred to the fourth metatarsophalangeal articulation in 60 ; to 
the third and fourth articulation in 6 ; to the second, third, and 
fourth in 6, and in but 6 was the fourth articulation free from 
pain. The pain is most often unilateral, or, if the second foot is 
affected, it is usually after a considerable interval. 

The affection is more common in females than in males. Of 
v 1 cases 64 were in women and 20 were in men. 

Anterior metatarsalgia is not an affection of early life, the 
average age in the reported cases being more than thirty years. 
It is relatively more frequent in private than in hospital practice, 
and not infrequently the patients are of a distinctly nervous 
type. In many instances it is supposed to be a family inherit- 
ance. The affection is usually extremely chronic. Occasionally 
the symptoms may cease spontaneously, and in such instances a 
particular pattern of shoe usually receives the credit of the cure. 

Morton considered the affection to be a painful affection of the 
plantar nerves due to compression or pinching by the adjoining 
fourth and fifth metatarsophalangeal articulations. This compres- 
sion was explained by the anatomical construction of the foot — 
i, .. the mobility of the fifth metatarsal bone which allowed it 
to roll above and under the fourth, its relative shortness w T hich 
allowed the head and base of the adjoining phalanx to be brought 
against the adjoining head and neck of the fourth bone, and, 
finally, by tin- peculiar distribution of the external plantar nerve 
between these bones that made it or its fibres more liable to 
injury. This natural mobility and thus the predisposition to 
compression might be exaggerated by a sprain, or possibly by 
rupture of the transverse metatarsal ligament, or the pain might 
!><* induced by wearing tight shoes, but in many instances no 
cause could be assigned. On this theory Morton advocated 
on of tie- head of the fourth metatarsal bone to remove the 
point of counter-pressure. This operation lias been performed 
many times, but practically no pathological changes in the re- 
: bone or in the surrounding parts have ever been discovered. 
In more recent year- the true significance of Morton'- neuralgia 
and of similar pain- in the front of the foot ha- been made more 

45 



706 ORTHOPEDIC SUBQEBY. 

clear by the Study of the relation of weakness of the anterior 
transverse metatarsal arch to the symptoms. Attention was 
first called to this point by Poulosson, of Lyons, and again by 
Roughton, Woodruff, and others, and in a much more thorough 
and convincing manner by Goldthwait, 1 of Boston, in 1894. 

The Anterior Metatarsal Arch. If one examines a normal 
foot one notices that the two middle metatarsal bones, the second 
and third, are slightly Longer and on a higher plane than their 
fellows. On the sole of the foot the areh is shown by the depres- 
sion immediately to the outer side of the muscular projection 
of the great toe-joint. When weight is borne all the metatarsal 
boiler are on the same plane and the arch is obliterated, but when 
the weight is removed the arch reforms with a certain natural 
re-ilicnev. In walking and standing the weight is balanced on 
the head of the third metatarsal bone, as shown by a thickening 
of the skin beneath its head, but the strain on the metatarsal 
areh is relieved somewhat by the balancing action of the muscles 
about the first ami fifth metatarsal bones, the inner and outer 
supports of the arch, and by the active assistance of the toes 
themselves. When the arch is weak or broken down this natural 
resiliency is lost, and, in some instances, the centre of the fore- 
foot is not only depressed but it is fixed in this abnormal attitude. 

In the ordinary type of depressed anterior arch the deformity 
may Ik- shown by an imprint of the foot, in which the flabby 
tissu, g ,,f the depressed arch encroach upon the clear space repre- 
senting the longitudinal arch, and obliterate what Goldthwait 
calls the re-entering angle to the outer side of the great toe-joint, 
which in the normal foot indicates the highest point of the meta- 
tarsal arch. In many instances, however, the imprint of the 
fool BUbject to Morton's neuralgia may be, to all intents, normal, 
ami. on the other hand, depression of the metatarsal arch, one of 
the very common results of improper shoes, may be present, yet 
unaccompanied by pain or discomfort. 

Depression of the anterior arch, the result of the loss of the 
activity of the accessory supports of the arch, predisposes to pain 
because of abnormal pressure upon the persistently depressed 
articulations from beneath, and it predisposes to pain, as the 
writer has endeavored 1 to explain, because the metatarsophalangeal 
joints of an arch, that is habitually depressed, are exposed to 
the dired lateral compression of a narrow or ill-shaped shoe. 

•'.n Medical and Surgical Journal, vol. exxxi. p. 233. 
Heal Record, August 6, 1898. 



DISABILITIES AXD DEFORMITIES OF THE FOOT. 707 

This point may be illustrated in the hand. When lateral 
pressure is applied, the hand is folded together and the anterior 
metacarpal areh is increased in depth, but if the fingers are dorsi- 
flexed so that it is fixed in a depressed position, then lateral 
compression causes great pain at all the articulations (Fig. 420) ; 
or if one finger is dorsiflexed and the corresponding metacarpal 
bone is thus forced below the level of its fellows, lateral compres- 
sion causes pain at the compressed joint. Or if the metacarpal 
bone of the little finger is made to override the fourth, lateral 
pressure causes pain usually of a more acute character than at 
the other joints, because the opportunity for direct pressure is 
more favorable. 1 Finally, if firm pressure is made upon one or 

Fig. 420. 



Position of the fingers corresponding to dorsiflexion of the toes, an attitude in which 
lateral pressure causes pain. 

the other side of the head of the depressed metacarpal bone of the 
dorsiflexed finger in the palm of the hand, a point of sensitive- 
ness, representing apparently the digital nerve, can be made out. 
The same experiments may be tried upon the foot with the same 
results, and it would seem to make clear the mechanism of the 
pain of Morton's neuralgia and the allied form- of discomfort at 
the front of the foot. 

Anterior metatarsal<ria is in most instances the result of weak- 
er depression of the anterior metatarsal arch as a whole or in 
part, and the quality of the pain corresponds fairly to the form 
of weakness or deformity. If, for example, the entire arch is 
rigidly depressed, as in certain rheumatic affections, the dis- 

' This anatomical peculiarity is well known to KhOOlrbO] 



708 ORTHOPEDIC srncKRY. 

oomforl is Likely to be caused, "m great degree, by the direct 
pressure <>f the sensitive depressed metatarsophalangeal joints 
on the sole of the -hoe; or, if lateral pressure is exerted as 
well, the discomfort or pain may be referred to the metatarsal 
arch in general. If the metatarsal arch is weakened, depressed, 
ami broadened, but not rigid, the discomfort is often referred, 
as in the preceding instance, to the centre of the arch, and this 
discomfort is increased, in some instances, by a painful callus 
representing abnormal pressure at this point. If one of the 
metatarsal bones falls below its fellows, the lateral pressure of 
a narrow shoe may cause neuralgic pain at this joint, but in 
many cases in which the anterior arch is depressed the patient 
make- but little complaint of pain. In certain instances, more 
particularly those of Morton's typical neuralgia, the foot may 
appear to all intents normal ; in such cases it may be inferred 
that the sharp and characteristic pain is, caused by pressure 
applied to the overriding fifth metatarsal bone, just as similar pain 
i- felt if the hand is suddenly compressed while the fifth meta- 
carpal bone i- in the same position. This theory is the more 
probable when one considers the symptoms; for example, the 
sensation of something slipping or moving, the necessity for the 
removal of the shoe to flex and extend the toes and to compress 
the foot, apparently with the instinctive aim of replacing a 
depressed arch, or a misplaced bone in the arch. It would also 
explain how the shoe may be the most direct of the exciting causes 
of the deformity, in that it compresses the forefoot and throws 
more weighl upon it by elevating the heel. If the arch is depressed 
or becomes depressed, or if a bone in the arch overrides another, 
this compression causes the symptoms. 

That classical Morton's neuralgia is but one expression of 
weakness of the anterior arch of the foot is illustrated by an 
analysis <>f 30 cases seen recently in private practice: 

The pain was ref.rnd w, the fourth toe in 12 

third and fourth toes in 4 

i, third, and fourth toes in . . .2 

" third toe in 3 

second and third toes in .... 2 

second toe in 6 

to all the toes in 1 

The rig Involved in 13 

left " ...!..! .7 

Both bet were affected in ' g 

•-four of the patients were females ; four were males. 

The Influence of the Shoe in Causing Disability and Pain. 
In the etiology of pain and discomfort about the anterior arch 



DISABILITIES AXD DEFORMITIES OF THE FOOT. 709 

oue must recognize the shoe not only as the direct cause of the 
pain, but also as the most important of the predisposing causes of 
weakness of the anterior arch, of which the pain is a symptom, 
since it compresses the toes, lifts them off the ground by its 
" rocker sole,'' and thus, by preventing their normal function, 
throws additional strain and pressure upon the arch. In fact, in 
a very large proportion of feet that are supposed to be normal in 
appearance and functional ability, the toes are habitually dorsi- 
flexed in a claw-like attitude, that shows entire disuse of their 
function both as to support and progression. Women wear shoes 
with narrower soles and higher heels than men, and this seems 
the most reasonable explanation of the fact that they are more 
subject to the affection. 

The shoe also predisposes to habitual elevation of the fifth 
metatarsal bone, because this bone almost invariably overhangs 
the narrow sole. The fourth metatarsal bone becomes, therefore, 
the outer support of the arch, and is almost always found to be 
on a lower level than the adjoining bones. This relation, together 
with a laxity of muscular and ligamentous support induced by 
injury or otherwise, may account for the location of the pain at 
this point in the majority of cases. Although in certain instances 
a neuritis may follow direct injury, yet this assumption is not at 
all necessary to explain the symptoms. Xor is it likely that the 
peculiar distribution of the nerves at this point has any direct 
influence on the pain, for the nerve supply of all the joints and 
all the toes is practically identical. 

Other Factors in the Etiology. Besides the general effect of the 
shoe, and the possible influence of an inherited predisposition to the 
affection, which seems evident in certain cases, or of weakness or 
direct injury of the anterior arch, one recognizes among the 
causes or complications of anterior metatarsalgia weakness of the 
longitudinal arch, or flat-foot, which may be combined with a 
depression of the anterior arch. Less often the longitudinal 
arch may be exaggerated in depth and the dorsal Ilex ion of the 
foot may be limited by a shortened tendo Achillis ; thus more 
pressure is brought upon the front of the foot. In these cases 
the pain may be increased by corns or calloused skin beneath the 
depressed bones, and in many instances the discomfort of the 
depressed arch of the ordinary type is, in gr< at part, caused by 
a sensitive corn or fibroma at the point of greatest depreg 
and the patient may be entirely relieved by it- removal. 
Contracted Foot 



10 



ORTHOPEDIC SURGERY 






Although ihf Bymptoms of anterior metatarsal gia may be 
explained in most instances by the primary effect of improper 
Bhoes, by weakness and abnormality of the foot itself, and by the 
local sensitiveness of the parts that are continually subjected to 
strain, pressure, and injury, yet in some instances the symptoms 
can be accounted for only by local neuritis; in others they are 
aggravated by goul or rheumatism or general debility, and, as 
has been mentioned in a Large proportion of the cases, the patients 
are of a distinctly nervous type. 

It may be stated, in conclusion, that anterior metatarsalgia in 
it- milder forms is a very common affection, and one rarely treats 
a patient who does not know of other cases similar to his own. 

Treatment. The most important local treatment is to provide 
the patient with a proper shoe. This shoe must be of proper 
shape with a thick sole, so broad that no 
lateral compression of the toes is possible, 
with a high arch, as suggested by Gibney, 
in order to remove a part of the pressure 
from the heads of the metatarsal bones, and 
a low heel. 

As an immediate treatment a firm band- 
age about the metatarsal region, as suggested 
by Morton, may aid in supporting the meta- 
tarsal arch, or, better, adhesive plaster 
strapping may be applied about the entire 
metatarsus, with the object of compressing 
the foot somewhat as a tight glove com- 
presses the hand. Beneath or slightly be- 
hind the affected joint or the depressed arch, 
a pad, preferably an oval piece of sole- 
leather, about one inch by three-quarters of 

tonrth an inch in size and one-quarter in thick- 
Lrsopbalangeal artio- . l 

whicb ii elevated ness with bevelled edges, may be fixed to 

pressed articulation. tll( ' s,,l( ' () ' the loot with adhesive plaster, so 

that depression of the arch or overriding of 

the adjoining bones may be prevented. This pad, suggested by 

PoulossoD and Goldthwait, usually relieves the pain, and when 

the exad place has been ascertained it may be fixed to the sole 

of the shoe. 

A^ a rule, however, a metal support will be found to be more 

comfortable and far more efficient. This may be constructed of 

light m.-,.] | 19 gauge upon a plaster cast of the sole of the foot, 




a brace for anterior mem- 

tarsal^ia. .1 indicates a 



DISABILITIES AXD DEFORMITIES OF THE FOOT. 711 

of which the natural depressions, indicating the anterior and the 
longitudinal arches, have been somewhat exaggerated. The 
anterior extremity of the brace is made as wide as the foot, and 
extends forward slightly beyond the metatarsophalangeal articu- 
lations. The brace serves to support the anterior as well as the 
longitudinal arch. In certain instances one or more of the meta- 
tarsophalangeal articulations may be sensitive to motion. In 
such cases the sole plate must extend from the heel nearly to the 
extremities of the toes in order to splint the foot for a time. If 
there is slight depression of the longitudinal arch it may be 
further corrected by raising the inner border of the heel and sole 
of the shoe ; but if it is more pronounced a flat-foot brace (Fig. 
411) may be employed, whose anterior extremity is modified to 
support the metatarsal arch, as is shown in Fig. 421. If, on the 
other hand, the arch is exaggerated and if dorsal flexion is 
limited, treatment with the aim of relieving this deformity will 
be necessary, as described under " contracted foot." When the 
immediate symptoms of pain and local discomfort have been 
relieved, the patient must endeavor to strengthen the natural 
supports of the arch by proper functional use of the foot, and by 
regular exercises of the muscles, more especially by methodical 
forced flexion of the toes, as this motion elevates the anterior 
metatarsal arch (Fig. 422). Massage of the foot aud forcible 
manipulation of the toes for the purpose of overcoming restriction 
of motion are of special value. 

If the anterior arch is rigidly depressed, as in some instances, 
its flexibility must be restored by manipulation or by forcible 
correction under anaesthesia before a brace can be applied. If 
the symptoms are very acute, and particularly if they have 
followed direct injury, the parts should be placed at rest and the 
anterior arch should be elevated and supported by a properly 
applied plaster bandage. 

In chronic and resistant cases, or when conservative treatment 
cannot be applied, resection of the neck and head of the meta- 
tarsal bone at the seat of pain may be performed as advocated by 
Morton. The operation is very simple. An incision is made 
over the dorsal surface of the joint, and the bone is divided by 
bone forceps. The toe is not, as a rule, removed, but after the 
operation it slowly recede- between the adjoining metatar 
phalangeal joints, causing a rather noticeable deformity. r I be 
operation Is, as a rule, successful, but in the majority of cases it 
is unnecessary. 



712 



ORTHOPEDIC sriKiERY. 



The general oondition of the patient should, of course, receive 
attention, and Local applications, electricity, and the like, may 
be of benefit in special cases. 

\ n cattus beneath the arch may require treatment, and 
in certain eases its removal may be the only treatment required 
other than an improved shoe. But, as a rule, the cause of the 
oallus is habitual depression of one or more of the metatarso- 
phalangeal articulations, so that cure can only be assured by 
supporting the arch and by strengthening its natural supports in 
the manner already described. 

Woodruff 1 described a case of what he called " incomplete luxa- 
tion of the metatarsophalangeal articulation," in which the 
Bymptoms, practically identical with those of Morton's neuralgia, 



Fig. 422. 




Exercise for the weakened metatarsal arch. 

are ascribed to an upward displacement of the proximal phalanx 
at the fourth metatarsophalangeal joint 

It may be stated in t his connection that in the ordinary forms of 
metatarsalgia patients often refer the pain and local sensitiveness 
to th«- anterior extremity of the metatarsal bone rather than to its 
lateral aspect Persistent dorsal flexion of the toes that is so 
<•■„ urn. »nly associated with depression of the arch may strain the 
capsular ligament, and, subjecting this portion of the joint to 
abnormal pressure, may explain the location of the pain. But 
f '" extreme cases it can hardly be classed as a subluxation. 

Another writer, Guthrie, 9 described a case in which intense 
pain followed overextension of the third phalanx upon the second. 
8nch oases are extremely uncommon, and need only be mentioned. 



!. January 18, 1887. 



2 Lancet, March 19, 1892. 



DISABILITIES AND DEFORMITIES OF THE FOOT 71 3 

Achillobursitis. 

Synonyms. Achillodynia, achillobursitis anterior, retro-cal- 
caneobursitis. 

Under the title of Achillodynia, Albert/ of Vienna, in 1893, 
called particular attention to an affection characterized by pain and 
sensitiveness about the insertion of the tendo Achillis, symptoms 
usually caused by irritation or inflammation of the small bursa 
lying between the insertion of the tendon and the bone (Fig. 423). 

Etiology. In the acute cases the cause of the bursitis often 
appears to be a strain of the tendon or direct injury, as the 
symptoms appear immediately after running or jumping or after 
a fall, sometimes after a long walk or bicycle ride. 

In the subacute cases the symptoms may begin almost imper- 
ceptibly, so that it may be impossible to assign a direct cause 
other than the pressure of the shoe, aggravated, it may be, by an 
exostosis of the os calcis beneath the insertion of the tendon or 
by concretions within the bursa. In many 
instances rheumatism, gout, gonorrhoea, or 
one of the infectious diseases appear to be 
associated, directly or indirectly, with the 
onset of the symptoms, or the bursa may be 
secondarily involved in tuberculous disease 
of the os calcis. 

Symptoms. In a typical oase pain is felt 
in the back of the heel at the insertion of 
the tendon ; the pain is increased by use of 
the foot, and particularly by the attitudes 
in which the strain on the part is increased, 
as, for example, in descending stairs. There ^^ZlT^l. 
is also sensitiveness to pressure about the 

back of the heel on either side of the insertion of the tendon. 
In most cases a slight swelling, often more prominent on the inner 
than the outer side of the tendon, indicates the situation of the 
bursa. 

In the chronic cases the enlargement of the bursa i- very 
noticeable, and, in addition, the entire posterior aspect <>f the heel 
often appears to be thickened. This i- due probably t<> the 
secondary irritation about the fibrous expansion of the tendon 
and the adjoining periosteum. In many cases the symptoms are 

1 Wiener med. Presse, Jam; 




71 i ORTHOPEDIC SURGERY. 

pronounced ; pain [a often feU in the bottom of the heel or it 
radiate- up the back of the leg. The patient, unable to use the 
power of the calf muscle, everts the foot in walking, thus subject- 
ing the arch to overstrain, so that the symptoms of the weak foot 
are often added to those of the original trouble. Not infre- 
quently, however, the two affections may be associated from the be- 
ginning in one or the other foot. The patient complains much of 
Btiffness and weakness at the ankle and subastragaloid joints. In 
the acute eases, or in acute exacerbations, there is usually burn- 
ing and throbbing pain characteristic of acute inflammation, but 
in the subacute form the pain is slight, and is troublesome only 
after overexertion. 

Pathology. The pathological changes do not differ from those 
found in and about other bursse under similar conditions. In 
the mild ease- the lining membrane is simply congested, and the 
cavity contains serous fluid. In the chronic cases the walls are 
much thickened, 1 the lining membrane is fringed and redupli- 
cated ; the contents are semisolid, and sometimes calcareous 
masses are present. Similar changes are found, however, in the 
bursse of apparently normal subjects, so that the condition of the 
bursa may not always correspond to the character of the symp- 
toms. Suppuration of the sac occasionally occurs, and it may 
be the -eat of tuberculous or syphilitic disease. In cases of long 
standing the parts adjoining the bursa, the expansion of the 
tendon, and the periosteum become thickened, so that the bone 
appears t«» he increased in breadth and may actually become so. 

Treatment. When once established the affection is usually 
of a very chronic nature, as is explained by the strain to which 
the sensitive pari i- -nbjected by the use of the foot. It is, 
therefore, important to apply efficient treatment at the beginning 
«>f the affect inn if an opportunity is afforded. Efficient treatment 
implies absolute rest, and in all cases of any severity, particularly 
those of acute onset, a well-fitting plaster bandage should be 
applied to hold the foot slightly inverted and at a right angle to 
the l<L r . This should be worn until all symptoms have subsided. 
In very mild cases, following immediately on a strain or overuse, 
simple rest with the application of heat, massage, and pressure 
may he efficient And in the subacute cases the symptoms may 
be relieved 1 ,y the ap] >1 ieat ion of a long, broad band of adhesive 
plaster, from the toes over the back of the heel to the upper 

:••!•. D. 7. f Chlr., Bfl. lxii. H. ] and 3. 



DISABILITIES AXD DEFORMITIES OF THE FOOT. 715 

third of the calf, the foot being slightly plantar flexed. This is 
firmly tixed by narrow strips of plaster about the metatarsus, 
the heel, and the calf. By this means pressure is exerted upon 
the bursa, and much of the strain is removed from the tendon. 

In persistent cases a brace may be used with advantage for the 
purpose of preventing strain upon the tendon. Two lateral 
uprights with a calf band and padded strap that crosses the upper 
third of the leg are attached to the shoe, provided with a stop 
joint at the ankle as used in the treatment of paralytic calcaneus to 
prevent dorsal flexion. (See Talipes.) As the patient is usually 
sensitive to jar, the heel of the shoe should be replaced by one 
of thick rubber. In connection with the brace the stimulation 
of the cautery and the pressure of the adhesive plaster strapping 
seem to hasten the absorption of the effusion in and about the 
bursa. If weakness or depression of the arch is present, as a 
result of the disability or combined with it, a foot plate should 
be applied, and general affections, with which the disability is 
sometimes associated, should, of course, receive attention. 

Operative Treatment. In persistent cases, in which the symp- 
toms are not relieved by treatment, the enlarged bursa should be 
removed by an incision on the inner side of the tendon, as the 
swelling is usually most prominent here. A plaster bandage is 
then applied and is continued until the symptoms have subsided. 
If the case is a chronic one, it may be advisable to divide the 
tendo Achillis in order to completely remove for a time the strain 
upon the sensitive part. In any case, a brace of the character 
already described may be required for a time after the plaster 
support has been removed. Operative treatment is, of course, 
indicated in acute suppurative inflammation, in tuberculous dis- 
ease, or if an exostosis beneath the bursa or concretions within 
the sac are present, as shown by an X-ray negative. 

Achillobursitis Posterior. 

Tenderness, pain, and swelling at the back of the heel may 
be due to inflammation of the small superficial bursa that Lies 
between the tendon and the skin. The cause is usually injury or 
the pressure of the shoe. The symptoms resemble somewhat 
those of achillobursitis anterior, but the swelling i- more super- 
ficial, and the pain is caused by direct pressure rather than by 
tendon on the tendo Achillis. In the ordinary case removal <>f 
the pressure will at once relieve the symptoms, but if the discom- 



7| ti ORTHOPEDIC SUIWERY. 

fort is considerable a plaster bandage may be worn for a week or 
more. 

Sensitive points at the back of the heel are usually caused by 
the pressure o{ the shoe. In rare instances prominent points, 
or exostoses of the os calcis arc present, that may require special 
protection or removal. 

Strain of the Tendo Achillis. 

Not infrequently, and usually as the result of strain or overuse 
of the foot, patients complain of symptoms similar to those of 
achillobursitis, but on examination one finds that the pain and 
sensitiveness arc referred to the tendon itself. There is no swell- 
ing at its insertion, or pain on lateral pressure on the os calcis. 
The sensitive area may be as high up as the junction of the 
tendon with the muscle, and, again, the midpoint of the tendon 
seems most painful. 

The cause in some cases may be a direct strain of the tendon 
or <»f the muscular fibres near its origin, or inflammation of its 
fibrous covering due probably to the same cause. The treatment 
is similar to that of the milder type of achillobursitis, by the 
adhesive plaster strapping, by rest, and, later, by massage. 
Recovery is usually rapid. 

Painful Heel — Calcaneobursitis. 

Pain referred to the bottom of the heel and sensitiveness to 
pressure on standing are common symptoms of the weak or flat- 
foot. Pain at this point may be one of the symptoms of achillo- 
bursitis also. In rare instances the painful point is clearly 
localized, and is confined to a small area in the neighborhood of 
the inner tuberosity of the os calcis. The cause of the symptoms 
in such cases may be an inflamed bursa lying between the perios- 
teum and the fatty tissue of the heel. Such bursa? may contain 
hard substances or even a fasciculated neuroma. 1 

More genera] pain and tenderness referred to the heel is often 
ran-,., I by direct pressure and bruising of the tissues by overuse 
of the feet. 

Treatment. Treatment must be directed to the condition of 
whirl, the pain is a symptom, and, as has been stated, it is most 
..ft. -n one of the symptoms of I he weak or broken-down arch. 

bier. Revue de Chir., August, 1895. 



DISABILITIES AND DEFORMITIES OF THE FOOT. 717 

If the tender point is localized, and if the pain is increased by 
jars, a thick rubber heel combined with an inner sole, so cut out 
as to remove the direct pressure on the sensitive point, will often 
relieve the symptoms. In persistent cases, in which the sensitive 
point is distinctly localized, operative intervention for the removal 
of the bursa is indicated. The tissues of the heel may be turned 
forward in a horseshoe-shaped flap, which will allow a thorough 
examination of the affected parts. 1 

Sensitiveness due to direct contusion, or bruising of the tissues 
caused bv overuse, must be treated bv rest and bv change of 
occupation, uuless a reduction of the body weight or improve- 
ment in attitudes relieve the symptoms. 

Plantar Neuralgia. 

Synonym. Plantalgia. 

Pain referred to the sole of the foot and sensitiveness to pressure 
on the plantar fascia are usually symptomatic of the contracted 
foot (cavus) ; less often such symptoms accompany the weak or 
broken-down arch. 

Pain, tenderness, and thickening of the fascia sometimes follow 
injury (rupture of the fascia), 2 and a similar condition has been 
described by Franke as one of the sequelae of influenza. 3 

Treatment. Pain in the sole of the foot, symptomatic of the 
contracted or of the weak foot, may be relieved by the treatment 
of the conditions of which it is a symptom. In the rare instances 
in which the fascia is itself injured or diseased, local rest, as 
afforded by the plaster bandage, is indicated until the acute 
symptoms have subsided. 

Ery thromelalgia . 

AVeir Mitchell 4 has described a series of cases characterized by 
attacks of heat, redness, pain, and often swelling mos< marked 
about the soles of the feet. Of 27 cases all but 2 were in women, 
many of whom were of a nervous or neurasthenic type. The 
affection appears to be a form of vasomotor disturbance. I disturb- 
ances of the circulation and burning pain in the soles of the Peel 
are common symptoms <>f tie- weak foot and of allied affections, 



1 Duplay. Clin. CMr. de l'Hotel Dieu, Serb 

2 Lederhose. Verhand. der Dent Q. I Chlr., XXIII. Konfi 
' : Archiv f. klin. Chlr., 1896, Bd. xlix. 

4 American Journal of the Med vol. lxxvi. 



L8 



ORTHOPEDIC sriUiKllY. 



but in suofa oases there is no! the flashing and swelling character- 
istic of erythromelalgia. In this affection the circulatory disturb- 
anoee are Dot, as a rale, confined to the feet, but are seen in the 
ml even in the upper extremities. 1 It deserves mention as 
a possible explanation of symptoms in obscure cases. 2 



Hallux Rigidus. 

Synonyms. Hallux flexus, painful great toe. 
Hallux rigidus is a painful affection of the great toe-joint, 
characterized by restriction of motion, particularly of the range 
of dorsal flexion. In advanced cases the first phalanx may be 
slightly plantar flexed together with its meta- 
tarsal bone ; hence the name hallux flexus, ap- 
plied by Davies-Colley, who first described the 
affection. 

The restriction of motion may be complete, as 
implied by the term rigidus ; the joint appears 
unduly prominent or enlarged, usually slightly 
congested, and pressure or forced movement 
causes pain. 

The symptoms of which the patient complains 
are a burning or throbbing pain in the joint, in- 
creased by standing, and particularly by walking, 
because of the enforced movement of the stiff 
and painful articulation. There are many cases 
in which there is no actual deformity of the 
joint or other noticeable change ; the restriction 
<»f motion is much less, and the symptoms are correspondingly 
Blight 

Etiology. Typical hallux rigidus is most common in adoles- 
cence, and it i- very often associated with the weak or broken- 
down foot. In Buch cases the toe is crowded into the narrow 
part <»f tie- shoe, and i- thus subjected to lateral and to longi- 
tudinal pressure ;t- well as to the additional strain that the 
attitude, characteristic of the weak foot, throws upon it. In 
some cases the habitual plantar flexion of the toe may be the 
result of an instinctive effort to support the weak arch (hammer- 
toe flat-fool — Nicoladoni). In other instances hallux rigidus is 
caused directly by traumatism ; as by stubbing the toe, by kicking 




The dotted outline 

the ^hiq-e of 

nit that 

may \»- inserted in 

the sole of the shoe 

for hallux rigidus. 



Kahane. Klin, thenp. Wochen., May 20, 1900. 
- Prei.' i of the Association of American Physicians, 1897, vol. xii. p. 



DISABILITIES AND DEFORMITIES OF THE FOOT. 719 

a hard object, or by other form of strain or injury. The affection 
appears to be, primarily, a form of periarthritis, caused by injury 
or pressure. The restriction of motion is in part due to muscular 
spasm, and in part to the irritative and accommodative changes 
in the ligaments and tendons. In more advanced cases changes 
in the cartilage and shape of the articulating surfaces, due to 
disuse of function and to pressure and friction, may be present. 

Treatment. If the rigid and painful joint is not associated 
with a weak arch, it may be relieved by providing the patient 
with a proper shoe which exerts no pressure on the sensitive part. 
Motion of the joint may be lessened by increasing the thickness 
of the sole, or, if necessary, it may be entirely restricted by the 
insertion of a brace of tempered steel between the two layers of 
the sole, as shown in the diagram. If, as in some instances, the 
flexed and painful toe is associated with rigid flat-foot, both 
deformities may be overcorrected, under anaesthesia, and retained 
in proper position by a plaster bandage, as a preliminary treat- 
ment. 

If the milder type of painful joint is associated with the ordi- 
nary weak foot, the treatment of the latter condition will usually 
relieve the symptoms. In this class, particularly among the 
poorer patients, the shoe may be raised on the inner side and 
the sole stiffened by means of the wedge-shaped sole, as already 
described in the treatment of the weak and flat-foot. If painful 
motion is restricted and the exciting causes of the disability are 
removed, relief of the symptoms is usually immediate. In the 
chronic cases, in which the pathological changes are more ad- 
vanced, excision of the joint may be necessary. 

Painful Great Toe-joint in Older Subjects. 

A similar condition of the joint is sometimes found in older 
subjects. In many instances the foot is well formed, and the 
restriction of motion in the joint is very slight; yet forced dorsal 
flexion causes pain, and long standing or walking Induces dis- 
comfort, particularly a dull ache in the joint and sharp neuralgic 
pain referred to the terminal phalanx. In gome cases tin- onsel 
of the symptoms may be ascribed to a long walk or " mountain 
climb/' in others to wearing tight shoes, and in some instances 
no definite cause can he assigned by the patient. In oat 
this type the symptoms are often supposed t«. he evidences 
of gout or rheumatism. Admitting that in certain instances the 



20 



ORTHOPEDIC SURGERY. 



discomfort may be aggravated by a constitutional disease, still no 
relief can be obtained by medication unless it is combined with 
the local treatment that has been described in the preceding sec- 
tion. The relief afforded by such treatment alone proves, in 
many instances, that the affection is purely local in its character 

;. i24). 

is has been mentioned, pain referred to this joint is a common 
symptom of the weak foot and of the contracted foot as well. It 
i- also caused by simple pressure on the joint, and by the use of 
improper shoes which force the toes into the abducted position. 

In rare instances pain directly beneath the great toe and sensi- 
tiveness to pressure about the sesamoid bones seem to indicate an 

Fig. 425. 




ngenital varus adduction without supination— a form of pigeon-toe. 

inflammation of the Tendon sheath or local periarthritis. If the 
discomfort is persistent the sesamoid bones maybe removed. As 
a rule, such symptoms occur only in combination with pain or 
deformity of the great toe-joint. 

Hallux Varus. 

Adduction of the greal toe is not infrequent in infancy, and it 
may be associated with a slight degree of varus deformity (Fig. 
125 . 'I1m- peculiarity attracts the mother's attention because of 
the difficulty of drawing on the socks. In many instances the 
muscles seem abnormally developed, and the toe appears to be 
somewhat prehensile in it- movements. 



DISABILITIES AXD DEFOBJIITIES OF THE FOOT. 



Treatment. The abnormal mobility may be checked by 
inclosing the toes with a narrow strip of adhesive plaster ; in any 
event, the ordinary shoe may be depended upon to correct any 

If the adducted toe is com- 



Fig. 420. 



residual deformity of this character, 
bined with varus, it represents a 
slight degree of club-foot that must 
be corrected in the ordinary manner. 
(See Talipes.) 

Pigeon-toe. 

Congenital hallux varus forms 
one variety of what is known as 
pigeon-toe, or the habitual turning 
in of the feet in walking. The in- 
ward rotation may be due also to 
bow-legs, or it may be an effect of 
congenital talipes that persists after 
the cure of the deformity, or of the 
exceptional variety of coxa vara in 
which the depressed necks of the 
femora are turned forward. In 
most instances pigeon-toe in child- 
hood is symptomatic of weakness 
either of the arch of the foot or of 
the knees (genu valgum). In such 
cases it is a conservative effort of 
nature that serves to check further 
deformity, and it needs no treat- 
ment other than that which may be 
applied to the weakness of which it 
is a symptom. 

In the exceptional cases, in which 
the posture is not symptomatic of 
weakness or the effect of deformity, 
the sole of the shoe may be raised 

slightly on the outer border. This will correct the attitude in the 
milder type, if combined with instruction and training. In ran; 
instances the in-toeing -ferns to be caused by limitation of the 
range of outward rotation at the hip-joints, a restriction that must 
be overcome by systematic stretching of the contracted part-. In 
and in the more obstinate cases of the simple type appa- 

16 




An appliance constructed of leather 
bands and elastic webbing for the cor- 
rection of Ln-toeing. Name of the in- 
ventor unknown. 



722 ORTHOPEDIC SUBOEBY. 

ratus may be applied, similar to that used in the after-treatment 
of congenital club-foot, to hold the feet in the proper attitude 
(Fig, li'ii). It must be borne in mind that the proper attitude 
of the feet i> one of parallelism not of outward rotation, and that 
Blight pigeon-toe will, as a rule, correct itself as the child grows 
older. 

Hallux Valgus. 

Hallux valgus is a deformity in which the great toe is turned 
outward t<> an exaggerated degree. Outward deviation of the toe 
ua so common, owing to the use of improper shoes, that it is not 
recognized as a deformity, at least from the popular standpoint, 
unless the joint appears to be much " enlarged," forming a so-called 
bunion. 

Hallux valgus is practically a partial dislocation of the phalanx 
upon the metatarsal bone. In well-marked cases the metatarsal 
bone is adducted or turned inward, so that an abnormal interval 
separates its head from its fellows, while the phalanx is displaced 
outward and articulates only with the outer condyle. The angle 
thus formed, or, more properly, the inner condyle of the adducted 
metatarsal bone, makes the prominent or "outgrown" joint (Fig. 
135). This projects sharply beneath the skin, and is exposed to 
injury and to the pressure of the shoe; thus a bursa develops 
beneath the skin, while a corn or callus forms on its superficial 
surface. The projecting bone, covered by the irritated bursa and 
the thickened skin, makes up the bunion. 

Ln many instances the other toes are displaced outward, in 
the direction corresponding to that of the great toe, or this may 
be rotated on it- long axis and lie above or beneath its fellows. 

Pathology. The pathological changes are such as usually 
follow deformity, disuse of function, and injury. The cartilage 
on the exposed condyle atrophies, the sesamoid bones, together 
with the tendon, arc displaced outward, the tissues on the outer 
side undergo accommodative shortening, while those on the inner 
-id.- are correspondingly Lengthened and attenuated. The surface 
of the bone beneath the irritated periosteum is often roughened 
and irregular, and exostoses may form about the condyle, and 
thus aggravate the effects of the external pressure. 

Etiology. The deformity is the direct effect of shoes that are 

narrow and of improper shape, and in some instances too 

short for the foot, so thai the great toe is subjected to lateral 

and longitudinal pressure, The deforming effect of the shoe is 



DISABILITIES AXD DEFORMITIES OF THE FOOT. 723 

increased if the arch is weak, so that the toe is forced forward 
into the narrower part of the shoe when the foot is in use. The 
deformity may be increased by injury or by the changes that 
follow gout, rheumatism, rheumatoid arthritis and the like, and 
in rare instances the distortion may be the direct result of such 
diseases ; but all other factors are of slight importance when 
compared to the deforming influence of the ordinary shoe. The 
deformity begins at a very early age; it advances more rapidly 
during adolescence, but the symptoms do not often become 
troublesome until later years. Both toes are affected, as a rule, 
although the deformity and its accompanying symptoms are 
usually more marked on one side. 

Symptoms. As has been stated, the slighter grades of defor- 
mity are not recognized as such, and it is usually because of the 
pain due to the irritated corn or bursa, and incidentally because 
of the outgrown joint, that the patients apply for treatment. 

Treatment. The symptoms in the ordinary cases may be 
relieved by providing a proper shoe, by which pressure ou the 
joint is completely removed (Figs. 407 and 432). The sole 
should be strong, and it should be slightly thicker along the inner 
side, so that the sensitive joint may be inclined away from the 
upper leather. In cases in which the deformity is not far 
advanced the use of a proper shoe that allows space for an 
improved position of the great toe, combined with methodical 
manual correction of the deformity and exercise of the disused 
muscles, while the toe is guided in the proper directions by the 
fingers, will relieve the symptoms promptly and practically cure 
the deformity. If the longitudinal or the metatarsal arches are 
depressed they should be properly supported (Figs. 404 and 421 ). 

Several forms of correcting braces have been devised t<> be 
worn during the day, a digitated stocking and special shoe being, 
of course, necessary. 

A simple device for holding the toe in an unproved position 
i- the Holden toe-post, recommended by Walsham and Bughes. 
This is a thin piece of metal so fixed in the front and inner side 
of the sole of the shoe that it separates the first and second toes 
from one another and holds the former in an improved position. 
It, of course, necessitates a special -hoc and a special Bhoemaker 
to fit it in its proper place. 

Sampson 1 make- the toe-post of tin and places it in a card- 
board inner sole, as illustrated in the diagrams 

1 Johna Hopkins Bulletin, January 



7 o, ORTHOPEDIC SURGERY. 

The use of a splint at oighl is also of some service. For this 
purpose a piece of celluloid about one-eighth inch in thickness, one 
[nob in width, and about six inches in length may be used. 
This, having been moulded to the proper contour by placing it 

Fig. 427. 



E 

c 



H 

Making the pattern for a toe-post. A heavy piece of paper folded once along the line A B. 
A 1> E and B C Fare cut away, leaving the tongue A D CB. AD should equal the depth 
of the shoe at that point, and A B should be as wide as the length of the slit in the card- 
b lard inner sole. The tongue is inserted in the slit, and the bases folded back and cut away 
to conform to the front of the inner sole. When removed and straightened out this forms 
torn in Fig. 428. 

Fig. 428. 



h F r 

Pattern of paper from which the tin is cut. The edges D D and C Care to be turned in. 
is folded along the dotted lines A B—D Cand D C forming the toe-post in Fig. 429. 



Tin 



Fig. 429. 




the toe-post ready to be inserted into the cardboard inner sole. Rough points;on 
the Upper and under surfaces of the base, which are made by punching holes with,* an awl, 
hold the toe-post to both the inner sole of the shoe and the cardboard inner.sole. 



Fig. 430. 




Cardboard' inner sole with toe-post and foot adductor attached. (Sampson.) 

in hot water. La secured by tapes to the inner side of the toe and 
foot 

It may be Mated that in the class of cases that can be suc- 
cessfully treated by mechanical correction few patients will be 



DISABILITIES AXD DEFORMITIES OF THE FOOT 725 

found who are sufficiently interested in the cure of the deformity 
to submit to the slight discomfort that the wearing of even a 
carefully adjusted brace entails. 

Operative Treatment. In cases in which the deformity is of 
long standing, and in which the projecting condyle or the exostoses 
make protection of the sensitive joint difficult, an operation is 
indicated. The primary object of the operation is to remove 
the projecting bone. This may be accomplished by a slightly 
curved incision about the inner aspect of the condyle, the centre 
being below the joint, so that the scar will not be subjected to 
pressure. The flap of skin is raised, the periosteum and part of 
the capsule are lifted from the bone, and the entire condyle is 
removed with a chisel, so that the surface is made perfectly 
smooth. Contracted tissues that resist a corrected position of 
the toe are stretched or divided, and the wound having been 
closed with sutures a plaster bandage is applied about the foot 
and toe. This may be worn with advantage for several weeks. 
The after-treatment consists in the use of a proper shoe and daily 
manual adduction of the toe, in order to retain the improved 
position. 

Cuneiform osteotomy of the metatarsal bone is an effective 
operation if the base of the wedge includes the projecting bone. 
Resection of the head of the metatarsal bone is an effective 
operation, and it may be indicated if the deformity is extreme. 

As has been stated, hallux valgus is often combined with the 
weak or broken-down arch ; in such cases the foot must be sup- 
ported by a properly fitted brace. This is of special importance 
after treatment by operation. 

Bunion. The discomfort of hallux valgus is caused in great 
part by the irritated bursa and the overlying corn. These 
symptoms may be relieved by rest and by hot applications. 
Afterward the callus or corn may be removed, and the sensitive 
bursa may be protected by a bunion plaster. Operative treat- 
ment should be deferred until after the acute symptoms bave 

subsided. 

Hammer-toe. 

Hammer-toe is a contraction of one of the toes, usually of the 
second, in which the first phalanx is dorsiflexed, the second 
plantar flexed, while the third may be flexed or extended. The 
contracted toe is overlapped by its fellow-: it- projecting dorsal 
surface is subjected to the pressure of the upper leather of the 
-hoe, and the terminal phalanx, forced against the sole of the 



726 ORTHOPEDIC SURGERY. 

shoe ami compressed by the adjoining toes, becomes flattened 
into a olab or hammer-like form. The nail is distorted and 
often u ingrown ;" in most cases a corn or callus forms upon the 
extremity of tin 1 toe, and a small bursa and corn over the pro- 
jecting knuckle on the dorsal surface. A third corn or callus is 
often found beneath the head of the metatarsal bone which has 
been forced downward hv the flexion of the toe. 

Bammer-toe is usually bilateral; it may be congenital and 
even hereditary, bnt it is usually acquired, the effect of shoes that 
are too short and too narrow. The second toe is deformed most 
often, because it is the longest and because it suffers most from 
the lateral compression as well. The deformity begins, as a rule, 
in early childhood, when, the growth of the foot being rapid, it 
is more likely to suffer from the effects of outgrown shoes, and 
socks as well. 

Symptoms. The symptoms are practically those of the corns 
or blisters caused by the pressure of the shoe, but they are often 
sufficiently troublesome to interfere seriously not only with the 
comfort, but with the ability of the patient. 

Treatment. The resistance to the rectification of the deformity 
i- caused by the accommodative changes that follow habitual mal- 
position. In cases of long standing all the tissues may be involved 
in the contraction, of which the most resistant are the shortened 
capsular and lateral ligaments of the first interphalangeal joint. 

The congenital hammer-toe of the infant may be treated by 
manipulation. When the resistance is overcome the toe may be 
held in proper position by narrow strips of adhesive plaster 
passed over and under it and about its fellows. In older children 
a dictation in the stocking will often hold the toe in place if the 
deformity is Blight and if a wide shoe is worn. In adult cases, 
in addition to the manipulation and shoe, a retention apparatus, 
in the form of a light plantar splint, or stiffened inner sole to 
which the toe can he attached, should be worn. If the deformity 
i- more resistant the toe may be straightened by force, aided, if 
necessary, by the subcutaneous division of the contracted ligaments; 
but in advanced cases the most effective treatment is resection 
of the joint. Sufficient hone should be removed to permit the cor- 
reotion of the deformity, or, in case of its recurrence, to prevent 
the projection of the joint above its fellows. A splint of celluloid 
or other material should be worn for a time. By this operation 
permanent relief may be !. and it is to be preferred to the 

mutilation of amputation. 



DISABILITIES AND DEFORMITIES OF THE FOOT. 727 

Overlapping Toes. 

Overlapping toes are very common among adults, owing to the 
pressure of the narrow shoe ; and not infrequently such deformity 
is seen in infancy and is apparently congenital. Deflected or 
deformed toes may be treated in infancy by manipulation and by 
support with strips of adhesive plaster in the manner described. 

In childhood exercise and proper shoes will usually correct 
acquired deformity. In older subjects an inner sole somewhat 
like a sandal, to which the toes may be attached by bands of 
tape, may be employed if the deformity is considered by the 
patient of sufficient importance to demand treatment. 

Exostoses of the Foot. 

Simple exostoses of the foot, as distinct from those that are 
incidental to disease, as, for example, to osteoarthritis, are, in 
most instances, induced by pressure upon a projecting bone 
of a somewhat deformed foot. The common examples are the 
hypertrophy of the navicular, often seen in flat-foot of young 
children, the projection of the cuneiform bones on the dorsum of 
the hollow or contracted foot, the enlargement of the internal 
condyle of the first metatarsal bone complicating hallux valgus, 
and the exostoses of the os calcis in achillobursitis. As a rule, 
the treatment of the deformity of the foot and the removal of 
pressure will relieve the symptoms without other treatment. 
Operative removal may be required in exceptional cases. 

Fracture of Metatarsal Bones. 

Fracture of a metatarsal bone, most often the second or the 
fifth, may occur without apparent cause other than walking. 
The pain and the subsequent swelling in such cases may be 
inexplicable until the diagnosis is made clear by an X-ray picture. 

Displacement of the Peronei Tendons. 

Permanent displacement of these tendons forward of tie- mal- 
leolus i- not uncommon as a result of paralytic deformity, par- 
ticularly talipes calcaneus, and in such instances \i gi 
n<> symptoms. Displacement of one or both of the tendons, or 
rather a laxity of their attachments that allow- an occasional 
displacement or slipping from the groove behind the malleolus, 



728 ORTHOPEDIC SVRVERY. 

may result iii Berious disability, because of the pain that follows 
the displacement and because of the weakness and insecurity of 
which the patient usually complains. 

The oause of fche laxity of the tissues that allows displacement 
in fed otherwise normal may have been injury, but as the affec- 
tion is often bilateral, the predisposition may be congenital. 

Treatment. If the displacement is recent, as when it follows 
injury, the tendons should be replaced, and the foot should be 
fixed in a plaster bandage until repair has taken place. If, as 
in certain instances, dorsal flexion is limited, the restriction 
should be overcome before the bandage is applied. If the dis- 
placement is habitual, a brace may be applied to restrain those 
motion- at the ankle that induce it. In the chronic cases an 
operation with the aim of fixing the tendons by deepening the 
groove in the malleolus, or by suturing the displaced sheath in 
its normal position, may be indicated. If on examination the 
oause of the displacement appears to be a shortening of the tendon 
it may be divided and lengthened in the ordinary manner. 

Shoes. 

The shoe as a factor in the etiology of deformity and disability 
has been mentioned several times in the preceding pages, but it 
is a subject of such importance that it would seem to call for 
special consideration. 

The object of the shoe is to cover and protect the foot, not to 
deform it or t<> cause discomfort; therefore, throne should corre- 
spond to the shape <>f the other. If the feet are placed side by 
ride the outline and the imprint of the soles will correspond to 
the accompanying diagram (Fig. 431). The outline demonstrates 
'!"• actual -i/<' and shape of the apposed feet, emphasized by 
enclosing them in straight line-. Thus, each foot appears to be 
somewhat triangular, being broad at the front and narrow at the 
heel. Th<- imprint -how- the area of bearing surface, and owing 
to the f;i'-t thai but a small portion of the arched part of the foot 
ipon the ground it appears to be markedly twisted inward. 
'lie- sole of the shoe, if it i- to enclose and support the bearing 
surface, must also appear to be twisted inward in an exaggerated 
righl or left pattern. It will be straight along the inner border 
to follow the normal line of the great toe, and a wide outward 
:. will be accessary in order to include the outline and thus 
avoid compression of the outer border of the foot (Fig. 432). 



DISABILITIES AND DEFORMITIES OF THE FOOT. 729 

This demonstration of the true form of the foot is almost an 
indispensable preliminary to an intelligent discussion of the rela- 
tive merits of shoes, and, indeed, it is somewhat of a revelation to 



Fig. 431. 



Fig. 432. 





Normal feet. 



Proper soles for normal feet. 



those who have thought of the foot only as it has been subordinated 
to the arbitrary and conventional standard of the shoemaker. The 
ideal, or shoemakers foot, upon which lasts are fashioned, is 
much narrower than the actual foot ; the great toe is not a power- 



FlG. 433. 



FIG. 434. 





Shoemaker's feet. 



- 



ful movable member, provided with active muscles, I ai ie small 
and turns outward, so thai the forefoot La somewhat pyramidal in 
form and turn- upward a- if to avoid contact with the ground. 



30 



ORTHOPEDIC SURGERY. 



Thia imaginary foot, drawn after the Bhape of the ordinary last, 
appears in the diagrams I Figs. 133 and 434). Upon it the sole 
of the shoe has been indicated, to contrast it with the shape of 
that accessary to include the outline of the normal foot. The 
actual fool is thus compressed laterally by the shoe until the 



Fig. 435. 




Skiagram of a foot modelled to fit the shoe, illustrating the etiology of hallux valgus. 



bing of the Leather, during the " breaking-in " process, 
allow- it to overhang the sole. The i^reat toe is forced outward, 
and, with it- fellow-, \B compressed, distorted, and lifted off the 
ground by the rocker-shaped sole (Fig. 436). Finally, although 
in the fool there is a well-marked metatarsal arch (convexity 
upward . the sole i& almost invariably fashioned with a convexity 



DISABILITIES AXD DEFORMITIES OF THE FOOT. 731 

downward. Thus the foot, according to the age at which the 
reshaping process is begun and the constancy of the application, 

is gradually changed in shape and altered in function (Fig. 435). 
This remodelling, however, is often accompanied by such dis- 
comfort that the individual rebels and wears a shoe with a square 
toe, which, from the conventional standpoint, is supposed to show 
a meritorious effort to follow nature. But the demonstration of 
the actual foot makes it evident that it is a properly shaped sole, 
which serves as a support, not the part which projects beyond 
the foot, that is of importance. If the shoe with the square toe 
is wider, and straighter on the inner side than another with a 
pointed toe, it is in so far an improvement. But, as a matter of 
fact, one of the worst types of shoe provided for children, in 
shape very like the old-fashioned coffin-lid, owes its popularity 
to the square toe. The same comment may be made on the 
so-called " common-sense " shoe, which is well named, since it 
may be assumed that a properly shaped shoe is an evidence of 
uncommon sense. 

Fig. 436. Fig. 437. 





The rocker sole. The Oat sole. 

The object of the heel is to make walking easier by inclining 
the body somewhat forward. The high, narrow heel is an 
insecure support, and aids deformity by throwing more strain 
upon the forefoot and pushing it forward into the narrowest part 
of the shoe. The heel is, of course, unnecessary in childhood, 
and should not be worn, since it limits the necessity for and 
therefore the use of the normal range of motion at the ankle- 
joint. The ordinary shoe by restricting the functional use of 
the foot, favors awkwardness and improper attitudes. It com- 
presses the toes, and is directly responsible for corns, bunions, 
ingrown toe-nails, and deformities, and indirectly it caufi 
aggravate- Dearly every weakness to which the fool is liable. 
This assertion does not need support of. argument, since in some 

a ee it has been proved by the personal experience of i 
shoe wearer. 



:;;•_> ORTHOPEDIC SURGERY. 

The shape of the proper shoe corresponding to the undistorted 
foot has al ready been demonstrated (Fi.u 1 . 482). The sole should 
l>e thick enough for protection, but not so rigid as to limit normal 
motion ; it should follow the imprint of the foot, projecting 
somewhat beyond the outline of the toes; it should be flat from 
end to end and from side to side (Fig. 437), and the upper leather 
should he capacious. In other words, the front of the shoe 
should l>e designed to permit and to encourage normal functional 
activity, the Blight adduction of the great toe, and the alternate 
expansion and contraction of its fellows, as may be observed in 
the barefoot child. The heel should be broad and low. Most 
adult feet are more or less deformed, and, therefore, better suited 
by an improved than by a perfect shoe. Of this class, what is 
known a- the wide AVaukenphast pattern is the best. In select- 
ing the better from the worst of the " ready-made " shoes, the 
breadth of sole, the angle of outward deviation of the soles when 
the two are placed side by side, and the capacity of the upper 
leather must be the determining points. 

The most effective work for reform can be accomplished by 
providing proper shoes for children and thus preventing deformity. 
The inspection of children's feet shows that atrophy and com- 
pression begin at a very early age, and if protection could be 
assured during the period of rapid growth, serious distortion 
might l>e prevented. 

Socks. Although of far less importance than the shoes, the 
socks worn by children deserve special mention as a factor in 
deformity, since they are often too short and too narrow and are 
made of unyielding material, so that the proper action of the toes 
i- restrained. Theoretically, the socks, like the shoes, should be 
rights and left- ; hut if they are sufficiently large and of a texture 
to expand readily to the shape of the foot, but little trouble need 
be anticipated on this score. 



CHAPTER XXII. 

DEFORMITIES OF THE FOOT. 

Talipes. 

In the preceding chapters the disabilities of the foot, of which 
the symptoms of pain and discomfort were of greater importance 
than actual deformity, have been described. One now passes to 
the consideration of the congenital and acquired disabilities, of 
which deformity is the most noticeable feature. 



Fig. 438. 




Paralytic equinus. Recovery from paralysis, but deformity ; 



Distortions of the foot arc practically, fixed positions in normal 
attitudes or what are exaggerations of normal attitudes ; in other 
words, the ordinary deformities can be voluntarily simulated, and 
the centres of motion, at which the fool is deformed, are the 

centres of normal motion. If the foot has been fixed in tin- 



;;;t OBTHOPEDIC SURGERY. 

abnormal attitude during the period of formation and rapid 
growth, or if it has been used for any length of time in the 
abnormal position, the deformity becomes exaggerated beyond 
the possibility of imitation, and secondary variations in its shape, 
sue, and nutrition follow. 

The deformities of the foot are grouped under the generic 
name of talipes, derived from talus (ankle) and pes (foot), signify- 
ing, therefore, a form of deformity in which the patient walks 
upon his ankles. Talipes was thus originally synonymous with 
the popular term club-foot, but at the present time it is used 
simply as a prefix to the descriptive titles of the different distor- 
tions while club-foot is usually applied only to the most common 
of the congenita] deformities, equinovarus, in which the distorted 
foot Lb club-like in form. 

Varieties. There are four simple varieties of the distorted foot 
or talipes : 

1 . Talipes equinus, the extended or plantar flexed foot. In well- 
marked cases the patient walks upon the heads of the metatarsal 
bones, an attitude that suggested the name equinus (horse-like). 

2. Talipes calcaneus, the dorsiflexed foot, in which the heel is 
prominent, and which alone bears the weight in walking; hence, 
calcaneus from calcaneum, the heel bone. 

In these forms the centre of motion is at the ankle-joint. 
Under the terms equinus and calcaneus are included not only the 
cases of marked deformity, but also those in which the range of 
dorsal or plantar flexion is sufficiently limited to interfere with 
function, even though the change in the contour of the foot is 
slight 

3. Talipes varus, the inverted foot. In this deformity the foot 
la turned in or adducted, and combined with the inward twist 
there is practically always a certain degree of supination or 
inversion; thai Is, the inner border of the sole is elevated and 
the outer border is depressed, so that the weight falls to the 
outer side of the centre of the foot. 

I. Talipes valgus, the everted foot. This deformity is the 
se of varus. The foot is abducted and the sole is everted, 
so thai in use the weight falls on the inner border. 

In these forme of lateral deformity the centres of motion are at 
the mediotarsal and subastragaloid joints. 

These simple deformities, in which the foot is persistently 
extended or flexed, or twisted in or out, are comparatively 
uncommon. 



DEFORMITIES OF THE FOOT. 



735 



Compound Deformities. As a rule, the deformities are com- 
bined in varying degree ; thus the overextended or the overflexed 
foot is usually twisted inward or outward, making four varieties 
of compound deformity : 

1. Talipes equinovaras, the extended and inverted foot. 

2. Talipes equinovalgus, the extended and everted foot. 

3. Talipes calcaneovarus, the flexed and inverted foot. 

4. Talipes calcaneovalgus, the flexed and everted foot. 



Fig. 439. 




Congenital calcaneus. In this form the arch is obliterated ; in the acquired form 
it is increased. 



In these more important deformities the arch of the foot may 
be increased or diminished in depth. It is, for example, usually 
increased in calcaneus and equinus, and it i- usually diminished 
in valgus; but this secondary or subordinate deformity is uol 
recognized in the ordinary classification. If the arch of the foot 
is simply exaggerated, the condition i- sometimes called pes 
cavus ; if it i- Lessened or lost, it is called pes planus. These 
slight degrees of distortion, in which the functional disability is 
usually more important than the deformity, are rarely class* 



736 



<)iyniori:i)ic srnaEiiv. 



forms of talipes. Simple cavus, the hollow or contracted foot, 
and pes planus, one of the forms of the common weak or flat-foot, 
have been described elsewhere. (Chapters XX. and XXI.) 

Etiology. From the remedial standpoint, the cause of the 
deformity is of far greater importance than its form. Thus, one 
divides the distortions of the foot into two groups: 

1. The congenital form, in which the foot, in process of forma- 
tion, has -lowly grown into deformity before birth. 

2. The acquired form, in which the foot, perfect at birth, has at 
a later time become distorted. 

The congenital club-foot may be considered simply as a twisted 
foot, of which the component parts, although distorted to a greater 
or less degree, are capable of regaining perfect form and function. 



Fig. 440. 




Congenital valgus. 



This is practically true of the great majority of cases, although 
there are instances in which congenital deformity is complicated 
by defective formation of the foot or leg, or in which the defor- 
mity is caused orat leasl accompanied by paralysis; as, for example, 
in certain forms of spina bifida or other defect or disease of the 
nervous apparatus. 

The acquired deformity is nearly always a consequence of 
paralysis of spinal origin (anterior poliomyelitis). Certain 
muscles or groups of muscles being paralyzed, usually in early 
childhood, the muscular force of the foot is unbalanced, and it is 
drawn into a distorted position by the contraction of the unop- 
posed muscles and by the influence of gravity. This distortion 
is confirmed and Increased by the accommodative changes in the 



DEFORMITIES OF THE FOOT. 



'37 



structure that accompany functional use and growth in the 
abnormal attitude. 

Far less often acquired talipes may be the result of paralysis 
of cerebral origin, of other forms of cord disease, and of local 
paralysis following- neuritis or injury to a nerve trunk. It may 
be caused by scar contraction, as after a severe burn, or by direct 



Fig. 441. 




Congenital club-hands and feet, combined with anchylosis of nearly all the join t^. 
(Compare with Fig. 1 1 



injury, or by disease that may interfere with subsequent growth 
Fig, 265). Such are, however, extremely uncommon oa 
Thus it is evident that whereas congenital talijx imple 

distortion capable of perfect cure, acquired talipes is capable only 
of rectification and not of perfect cure unless recovery from the 
original disease, of which it is a result, has taken place. 

17 






ORTHOPEDIC srUdKRY 



Etiology of Congenital Talipes. As of other congenital defor- 
mities, the etiology of talipes is more or less conjectural. Occa- 
sionally the influence of inheritance is apparent, and, again, two 
or more children with club-foot may be born of the same mother; 
l>ut, a- a rale, nothing bearing upon the deformity appears in 
the family or personal history. The most reasonable explanation 
as applied to the majority of cases is the mechanical. This is, 
in brief, the theory that the foot has from some cause remained 



Fig. 442. 




The etiology of congenita] club-hands, club-foot, and anchylosis of the joints. The habitual 
attitude at birth. Photograph at age of three months. (See Fig. 441.) 



f«»r a Longer or shorter time in a constrained or fixed position, 
and has thus grown into deformity. 

It has been claimed by Ksch rich t 1 and also by Berg 2 that about 
tic- third month of intra-uterine life the thighs of the embryo 
are abducted, flexed, and rotated outward, the legs are crossed, 
;it1,1 ,M " feel : "'«' plantar flexed and adducted, so that the inner 

1 DtOtSCbe klinik, 1861, No. 44. 

J Berg. Archive- of Medicine, New York, December 1, 1882. 



DEFORMITIES OF THE FOOT. 739 

surfaces of the thighs, the tibial borders of the legs, and the 
plantar surfaces of the feet are held in close apposition to the 
abdomen and to the pelvis of the foetus. Later there is an inward 
rotation of the legs, so that the feet are turned gradually outward 
until the soles are brought into contact with the uterine wall, the 
feet then being in the attitude of abduction and dorsal flexion. 
According to this theory, there is a regular succession of attitudes 
during intra-uterine life. If the inward rotation of the lower 
extremity is prevented or if it is incomplete, the foot, remaining 
in the original position, becomes deformed. Thus equinovarus, 
being the normal attitude of the early and middle period of intra- 
uterine life, is not only the most common, but it is the most 
intractable of the congenital deformities. But if the constraint 
or pressure is not exerted until a later period, after rotation has 
taken place, when the foot has attained or nearly attained its 
normal size and shape, it will then induce the rarer and compara- 
tively slight grades of deformity, such as calcaneus or valgus. 

This theory, which seems interesting and reasonable, appears 
to rest on a very insecure basis. Bessel Hagen 1 states that in 
embryos of 30 mm. in length the foot is in extreme plantar 
flexioD ; in those of 90 to 100 mm. the foot is at a right angle to 
the leg ; and from this size to that at full term the foot may be 
found in any position — abducted, adducted, or dorsiflexed. He 
states, also, that supination is not the usual attitude at an early 
period, but is more common near the termination of intra-uterine 
life, and when it is present it is more often combined with dorsi- 
flexion. In other words, there is no time when the foot regularly 
and normally assumes the attitude of club-foot, from which it is 
changed by the rotation of the limbs. Scudder, 2 after similar 
investigations, arrived at practically the same conclusions. He 
states that there is no necessary relation between the age, tin- 
rotation of the limbs, and the position of the feet. 

Although the rotation theory may not be absolutely accepted, 
still it would appear that there is, during the process of develop- 
ment, a more or less regular change in the attitudes of the Limbs 
and feet. If they are fixed in one position during this period of 
rapid growth, distortion must follow; if the constraint Is slight, 
and if its influence is exerted at a late period, the deformity will 
be slight ; if it occurs at an early period, the deformity will !«' 
more resistant. 

1 Die Pathologie und Therapie d« Klurnpf. rg, 1899. 

-ton Medical and Surgical Journal, Octoh 



'40 



ORTHOPEDIC SURGERY. 



( me of the causes of constraint, and thus of ultimate deformity, 
appear- to be the interlocking of the feet. Many museum speci- 
mena -how this, and in some of the cases of talipes seen during 
the first week of life the feet may be replaced in the attitude in 
which they had beeu fixed before birth (Fig. 281). Intra-uterine 
pressure, although not usually the direct cause of club-foot, 
undoubtedly has an influence in aggravating the deformity. The 
effect of pressure is not infrequently shown in atrophic areas of 
akin, and bursa? even are sometimes fouud over prominent bones. 



Fig. 443. 




Intra-uterine " amputations." The patient is a tailor. 



Entanglement in the umbilical cord, the direct pressure of intra- 
nterine or extra-uterine tumors, and the like may be mentioned 
also as possible causes. 

Evidence of restraint and of abnormal attitudes of the limbs is 
Been nol infrequently in connection with club-foot; for example, 
in hyperextension or fixed flexion of the knees, and in cases of 
extreme deformity, the foot is often smaller than normal and 
otherwise asymmetrical. The distorted foot may be imperfect 
'" structure; toes may be absent, "spontaneous amputation" 
Fig- 143), or constricting bands about the leg or foot maybe 



DEFOBMITIES OF THE FOOT. 74 1 

present. Such abnormalities are usually ascribed to amniotic 
adhesions. Talipes may be combined with evidences of impaired 
or arrested development ; with harelip, extrophy of the bladder, 
spina bifida, and absence of patella? ; or with other deformities, 
such as club-hand and wryneck, fixed flexion at the knees, and 
the like ; or there may be evidence of intra-uterine disease, as 
in anchylosis of joints (Fig. 441) or so-called foetal rickets. 
Finally, deformities of the foot may accompany or are caused by 
absence of bones, as of those of the foot ; or other deformities 
and malformations, showing evidently an abnormality in the 
original make-up of the germ. This latter group, which includes 
the complications of club-foot and imperfection of structure, is 
comparatively small, and, as has been already stated, in the 
great majority of cases congenital club-foot is a simple deformity 
capable of perfect cure. 

Statistics. The most accurate statistics are those compiled 
from the records of the Hospital for Ruptured and Crippled. 1 
In the combined statistics are included the data of 3453 indi- 
vidual cases of talipes. Of these 1650 were congenital and 1803 
were acquired. The relative frequency of the congenital and 
acquired forms of talipes has given rise to much discussion in 
the past, and statistics on this point are at considerable variance 
with one another. This may be explained by the fact that 
acquired talipes is. as a rule, a preventable deformity. At the 
present time the extreme degrees of acquired talipes are compara- 
tively rare, and the deformity is usually of a much slighter grade 
than the corresponding form of congenital distortion. 

Males. 
Sex of congenital talipes .... 1065 

Percentage 64. 5 

Sex of acquired talipes .... 975 
Percentage 54.1 

Congenital talipes is much more common among males than 
among females. All statistics are in accord upon this point. 
Acquired talipes is more equally divided between the - 

Right. Left. 

Foot affected in congenital talipes 510 440 710 1660 

Percentage .... '2G.r, 42.7 

Unilateral OO'i 57.2 per cent. Bilateral 710 42.7 per cent 

Right. , Both. 

Foot affected in acquired talipes 7-1 

Per .... I 42.6 M.1 

Unilateral 1 percent Bilateral 254 - 14.1 pel 



Females. 


Total. 


585 


1650 


35.5 




828 


1803 


45.8 





W. R. Towneend. A Statistical Paper on Clubfoot Transactions of 

of the State of New York, 1890. These statistics were supplemented for dm by Di 
Waller. 



742 



ORTHOPEDIC SURGERY. 



In congenital talipes the deformity is nearly as often of both 
as of one foot, while in the acquired form unilateral deformity is 
far more common. In each variety the right foot appears to be 
more often affected than the left 

I'm \\\.\ \ rivi: Frequency of the Different Forms of Congenital 

Talipes. 

Cases. Percent tage. 
Equinovarus 1272 77.0 

^as 123 7.4 

Varus 85 5. 1 

neovalgtu 52 3.1 

Kquinus 40 2.4 

Calcaneus 28 1.7 

Equiuovalgus 28 1.7 

tak-aneovarus 7 

5 

Yalgocavus 1 

Equinocavus . 1 

Different deformity in each foot 18 

Total 1660 

Relative Frequency of the Different Forms of Acquired Talipes 
Together with the Etiology. 



Spinal. 

Anterior 

polio- 
myelitis. 



Hemi- 
plegia 



Cerebral. 

Other 

forms of 
Para- paralysis. 



Trau- 
matic. 



Equinovarus . 
Equinus. 
:ieus 
Valgus . 

i ;< 
Calcaueovalgus 

- 
Calcaneocavus 
Equinocavus 
calcaneovarus 

u . 
Varocavus 









479 

321 

219 

134 

114 

76 

41 

12 

22 

11 

35 

1 



Deformity different on each side 



1465 



plegia. 



105 



35 



Total. Perct. 



95 



575 

462 

224 

173 

122 

78 

49 

12 

24 

11 

36 

2 



32.5 

26.1 

12.6 

9.7 



50 



4.4 
2.7 



1.3 
2.0 



Anterior poliomyelitis 1465 = 82.8 per cent. 

ral 200 = 11.3 

Traumatic 95 = 5.3 " 



Comparative Frbqueni y of the Different Forms of Talipes, 
kgj mtal and Acquired. 

Congenital. Acquired. 

'■varus 77. o per cent. 32.5 percent. 

« 7.4 9.7 

VMTUi ....... 5.1 2.7 

meovalgus 3. 1 " 4.4 " 

2.4 • 26.1 

1.7 " 12.6 " 

It will 1»«- noted that in three-fourths of the congenital cases 
deformity is equinovarus, and that equinns and calcaneus, 



DEFORMITIES OF THE FOOT. 743 

rare as congenital deformities, comprise &8 per cent, of the 
acquired forms. 

Occasionally the deformity is different in each foot, far more 
often in the acquired than in the congenital form (50 of the 
former, or 19 per cent., of the 2o4 acquired bilateral deformities 
as compared with 18, or less than 3 per cent., of the bilateral con- 
genital). In 7 of the 18 congenital cases the deformity was 
equinovarus on one side, calcaneus on the other ; in 3, equino- 
varus and calcaneovalgus, and in 3, simple varus and valgus. 
The 50 cases of acquired talipes represented every combination 
of deformity. 

In 31, or 4 per cent., of the 735 cases of congenital talipes 
tabulated by Waller the distortion was combined with other con- 
genital defects or deformities, viz., in 12 cases with double club- 
hands; in 6 cases with defective development of the hands, 
webbed lingers, and the like ; in 7 cases with spina bifida ; in 3 
eases with absence of one or more bones of the leg ; in 1 case 
with torticollis ; in 1 case with harelip ; in 1 case with disloca- 
tion of the knee and anchylosis of an elbow ; in 2 cases with 
general rigidity and deformity of the joints. 

The Anatomy of Congenital Club-foot. Talipes Equinovarus. 
Congenital talipes is, in the great majority of cases, the form in 
which the foot is twisted inward and downward, so that in 
extreme cases it resembles the club-like extremity that ha- re- 
ceived the popular name of club-foot. The ordinary congenital 
club-foot, in early infancy, is simply a foot held in an exagger- 
ated attitude of plantar flexion, adduction, and supination. The 
dorsum of the foot looks forward and slightly outward and 
upward, the plantar surface is abnormally concave, and look- 
backward, inward, and downward. The foot often seem- some- 
what smaller than normal, and the heel appears to be ill-fonned. 
Upon the outer dorsal surface the body of the displaced astragalus 
projects; the external malleolus is prominent, while the internal 
malleolus lie- deep beneath the redundant tissues of the internal 
aspect of the foot. 

In many instances the turning inward of the foot ifl BO extreme 
that it conceals the equinus element of the deformil 111;. 

Thus equinovarus Is often classified ;i- varus, especially by Eng- 
lish auth 

The internal structure <>f the foot i- rearranged to correspond 
to the external contour; thus the relation of the bones to one 
another, and even the shape of tin- individual bones, are m< 



744 



oimioPEDIC SURGERY. 



Less altered as the deformity is more or less of an exaggeration of 
the attitudes that the normal foot is capable of assuming. These 



Pig. 444. 




Typical congenital equinovarus (club-foot). 
Fig 445. 







jalUfl in club-foot. A, astragalus of a normal infant; 1, from 
j fn.m Within ; 8, from without. B, the astragalus in club-foot in the same posi- 

• ~ are most marked in the astragalus and os calcis. The 
gains is thicker at its external than at its internal border, 
■ in. -what wedge-shaped from without inward; it is plantar 



DEFORMITIES OF THE FOOT. 74 5 

flexed, so that a large part of its body protrudes from between the 
malleoli. Its neck is often somewhat longer than normal, and 
it is, as a rule, depressed and deflected inward (Fig. 445, B). 
The os calcis is also in an attitude of plantar flexion ; the internal 
tuberosity is drawn upward to the vicinity of the internal malleo- 
lus, its anterior extremity looks downward and inward, and it is 
often bent inward, corresponding to the deformity of the neck of 
the astragalus. Its external surface looks downward and for- 
ward, and it lies directly beneath the astragalus instead of to its 
outer side, as in the normal relation. 

The navicular is drawn inward and upward, and articulates 
with the inner part of the deflected head of the astragalus ; it 
lies in close proximity to and is often in contact with the iuternal 
malleolus ; the cuboid is displaced upward and inward, and lies 
to the inner side of the anterior extremity of the os calcis. The 
remaining bones are changed in position, but not materially in 
shape. In many instances the tibia is rotated inward upon the 
femur, and this inward rotation of the leg may persist after the 
deformity of the foot has been corrected. Less often the tibia is 
slightly twisted inward on its long axis. In other cases there is 
often a moderate degree of knock-knee and laxity of the liga- 
ments at the knee. As a rule, however, these are secondary or 
compensatory effects of club-foot that do not appear until the 
child begins to walk. 

The ligaments are altered to correspond to the changed rela- 
tions of the bones. Those on the short side are more or less 
resistant, according to the duration of the deformity. The 
muscles are normal as to their structure and their origin and 
insertion, but the direction of the tendons as they pass across the 
foot is altered somewhat. Those attached to the inverted side, 
the extensor and adductor group, are shortened and are relatively 
stronger than those on the outer side, which arc Lengthened and 
atrophied from disuse. 

T<> sum up: all the component parts of the foot participate in 
the deformity. The most noticeable changes in the bones are in 
their position and relation to one- another, but the astragalus, Ofl 
calci-. and oavieular bones are usually distinctly abnormal in 
contour. 

Hie most resistant structures in the deformed foot are the . 
plantar fascia and the ligaments that bind the scaphoid, th< 
calcis, and the interna] malleolus to one another. The muscles 
that are most active in retaining and increasing the deformity are 



i»; 



nirrimri:i>ic surgery. 



the tibialis anticus, the tibialis posticus, and the combined gas- 
trocnemius and soleus. 

The changes that have been outlined, which are comparatively 
Blight and which may be easily rectified soon after birth, become 
more marked as the part develops; and when the child begins 
to walk the weight of the body, combined Avith growth and func- 
tional use in the abnormal position, increases and fixes the 
deformity. 

In the adolescent or adult type of club-foot that has never 
been treated the deformity is so extreme that the patient actually 

appears to walk on the out- 
side of his ankles, as the term 
talipes implies. The feet 
turn directly inward, or even 
inward, upward, and back- 
ward, and the peculiar walk, 
by which interference of in- 
verted feet is avoided, has 
given another name (reel 
foot) to the deformity. 

In such cases knock-knee 
is usually well marked. 
This, although it may be 
present at birth, is, as has 
been stated, usually a second- 
ary distortion caused in great 
part by the accommodation 
to the deformity ; that is, by 
the diminution of the base 
of support and by the inter- 
ference of the feet (Fig. 449.) 
The legs are shrunken 
from disuse. Over the outer 
border of the foot, in the 
neighborhood of the cal- 
caneocuboid articulation, 
there is a large callus with 
an underlying bursa. The 
fool itself is atrophied and is much smaller than the normal. The 
changes in the bones are much more marked; only a small part 
of the articulating surface of the astragalus lies between the 
malleoli, and this posterior extremity is flattened out to the shape 




Talipes eqnloovanu In adolescence, apparently 

of tbe acquired form, showing the displacement of 

ition to the scaphoid, also 

cophyand distortion of the bones of the leg. 



DEFORMITIES OF THE FOOT. 



747 



of a wedge. There is consequently backward displacement of the 
leg bones, which is most apparent in the position of the external 
malleolus. In fact, the changes in the foot may be so great as 
to make the component parts almost unrecognizable (Figs. 444, 
445, and 446). All the bones of the foot are more or less 
atrophied, and the normal area of cartilage has, to a great extent, 
disappeared from the articular surfaces of the disused joints. 



Fig. 447. 



Fig. 448. 




Talipes equinovarus. 
The tendons on the front of the foot. Showing the tendons in the sole of the fool and 

the extreme displacement of the OB calclfl. 



In this advanced stage the normal functional activity of tin- 
foot has disappeared. It is practically a simple rigid support, 
to which the patient has bees so long accustomed that be may 
walk with comparative <■;!-<■ and with no discomfort other than 
that caused by the corns and bunions at tie' pressure points. In 
these extreme cases, cure in the -rn-<- of perfed functional 
recovery is, of course, out of the question ; but relief of the 



7 |s ORTHOPEDIC SURGERY. 

deformity — that is, replacement of the foot in the axis of the leg, 
at a right angle to it and in the plantigrade attitude — is nearly 
always possible. 

Symptoms. The symptoms of congenital club-foot have been, 
to all intents, included in the description of the deformity. The 
functional disability is, of course, considerable, although some 
patients are surprisingly active and are able to walk long dis- 
tances. As the discomfort from club-foot is due almost entirely 
to the corns or inflamed bursa? over the bony prominences, its 
degree depends, of course, upon the use to which the foot is sub- 
jected. 

Treatment. In considering the treatment of congenital club- 
foot it is customary to divide it into several classes corresponding 
to the degree of resistant deformity. 

The first class would include the very slight or non-resistant 
cases in which the deformity may be almost entirely corrected by 
slight manual force. 

The second class comprises those cases in which a certain 
amount of varus and well-marked equinus remain, which it is 
impossible to overcome by manipulation. 

The first and second classes include the forms of infantile 
club-foot. 

The third class comprises the cases of more extreme deformity 
and those in which the resistance to the correction is great, as in 
many of the cases in early childhood or those of later years that 
have been inefficiently treated. 

A fourth class would include the untreated cases in the adoles- 
cenl or adult. 

Congenital club-foot (talipes equinovarus) treated at the 
proper time — that is to say, in early infancy and in a proper 
manner — in a great majority of cases may be perfectly cured both 
i form and function. 

The club-foot in childhood, in which treatment has been de- 
layed or in which it has been ineffective, may be practically 
cured as to form and function, but a certain amount of atrophy 
of the fool and Leg persists as a consequence of the disuse of the 
distorted part. 

Club-foot in the adult may be made straight, but perfect func- 
tional cure is, of course, impossible. 

Although congenita] olub-foot is an eminently curable defor- 
niitv, y.-t perfect and permanent cure requires minute attention 
to details during the aetiv< of treatment, supplemented by 



DEFORMITIES OF THE FOOT 749 

long-continued and careful supervision after the cure is supposed 
to be complete. Xo other deformity presents such a record of 
failures and incomplete cures, of relapses after apparent cure, of 
tedious and ineffective treatment by braces, and of unnecessary 
and mutilating operations. Some of the failures may be explained 
by the neglect of the parents or by want of opportunity. A few 
are due to the unusual obstacles in the deformity itself, but by 
far the greater number must be accounted for by failure of the 
physician to apprehend the true nature of the deformity or by 
his inexperience in the practical details of treatment. 

Principles of Treatment of Infantile Club-foot. The infantile 
club-foot is, as has been stated, simply a twisted foot. It is true 
that there are slight changes in the bones ; but the bones of an 
infant's foot are represented by yielding cartilage, which will 
rapidly reform under changed conditions. The ligaments, which 
are accommodated to the deformity, may be easily stretched, 
together with the more resistant muscles and their tendinous 
insertions, and when the proper relation of the bones to one 
another has been restored the joints will undergo an accommoda- 
tive transformation. 

The treatment of club-foot may be divided into three stages : 

1. The rectification of the external deformity. 

2. The support of the foot in proper position during the 
process of transformation of its internal structure and until the 
normal muscular power, unbalanced by the deformity, has been 
regained. 

3. The period of supervision. This would include the treat- 
ment of possible complicating deformities at the knee, the laxity 
of ligaments and the like, as well as the oversight of the func- 
tional use of the foot and the limb during the early year- <»f life 

On examining the infantile club-foot one will notice the same 
muscular activity that characterizes the normal foot. Tie- normal 
infant moves the foot in various directions, in a more or less 
regular alternation of p<>~titrc-, but the motion of the club-foot i- 
in one direction only, that toward which the foot is turned. The 
muscles on the back and inner side of the leg, which arc alone 
active, become relatively irritable and hypertrophied as compared 
with those on the front and outer side that arc disused. Thus 
muscular activity of the deformed fool is in reality harmful, 
because it increases deformity and still further disturbs the mus- 
cular balance. For this reason the temporary restraint of motion, 
necessary during the rectification of the deformity, may be con- 



750 ORTHOPEDIC SURGER V. 

sidered rather of advantage than otherwise. When movement 
ifl again allowed and encouraged it must be in the directions 
opposed to the attitudes of deformity, with the aim of so strength- 
ening the weakened group of muscles at the expense of the 
Btronger that the balance of muscular power may be re-established. 

The First Stage of Treatment. Rectification of Deformity. It 
should be stated at once that "rectification of deformity" does 
not mean apparent symmetry, a misapprehension to which the 
majority of failures in treatment may be ascribed. It means that 
when deformity is really rectified all contracted and resistant 
parts must have been so elongated that every passive motion and 
attitude possible for the normal foot is equally possible and as 
easily attained in that which was deformed. This is functional 
rectification as contrasted with the simple straightening of external 
deformity. 

The most important part of the club-foot deformity is varus. 
The foot that is rolled over and twisted inward to the attitude 
of extreme adduction (Fig. 444) must be untwisted and forced 
into an attitude of extreme abduction or valgus, the so-called 
overcorrection (Fig. 440). Until this is accomplished no atten- 
tion whatever need be paid to the residual equinus. There are 
two reasons for dividing the procedure into two parts: First, that 
the attention of the surgeon may be concentrated on one and the 
most important part of the deformity; second, because by this 
preliminary untwisting the os calcis is brought into the upright 
position, into its proper relation to the astragalus, to the bones 
of the leg, and to the tendo Achillis, so that the true degree of 
((jiiiiiii- may be appreciated. 

Preliminary Manipulation. As a rule, the second or third week 
of life i- a- early as mechanical treatment can be undertaken. 
Until then preliminary manipulation by the nurse, more particu- 
larly manual straightening of the deformity by gently drawing the 
foot toward abduction and retaining it in the improved position 
for a few minutes, a- often as is possible, may be of service in 
overcoming its resistance. \< a treatment by itself, however, 
simple manual correction is tedious and ineffective, although 
partial cures have been attained by perseverance in this means 
alone. 

Mechanical Treatment. This is the treatment of choice and 
routine for infantile club-foot, and two methods may be described : 

1 . By tie' j>la-t<T bandage. 

2. By some form of simple splint. 



DEFOBMITIES OF THE FOOT. 



751 



The principle of the two is essentially the same. The foot is 
drawn toward an improved position and retained there by the 
plaster bandage, or it may be fixed to some form of metal splint 
or brace whose shape is gradually changed from week to week, 
as the resistance lessens. 

Gradual Rectification of Deformity by Means of the Plaster 
Bandage. In this treatment care should be taken to avoid undue 
pressure, irritation of the skin, or insecurity of the bandage. 
One should place shreds of cotton between the toes ; and the 
outer aspect of the ankle, where the skin is thrown into folds 



Fig. 449. 




Neglected club-foot, showing the secondary knock-knee. 



when the foot is straightened, should be smeared with vaseline 
A narrow strip of adhesive plaster, long enough to reach 
from the knee to a point an inch or more below the heel, is 
applied to the outer side of the leg. A thin layer of cotton is 
wound about the Leg, just bdow the knee, in order to protect the 
skin from the hard margin of the plaster bandage, and a similar 
strip is carried about the toes. The foot is then drawn gently 
toward the abducted position as far as may be without causing 
discomfort While it is held in this attitude a narrow bandage, 
preferably flannel or cotton flannel, [g smoothly applied to the leg 



752 ORTHOPEDIC SURGERY. 

and foot, the band of adhesive plaster being drawn out between the 
folds about the ankle A very light plaster bandage is then applied 
from the upper part of the leg to the extremities of the toes, and 
into this bandage the projecting strip of adhesive plaster is 
incorporated, bo thai no displacement of the dressing is possible. 
The turns of both the plaster and the flannel bandage should be 
made from within, downward and outward, so that the tension aids 
in retaining the foot. When the plaster bandage, which during the 
hardening process has been constantly rubbed and manipulated so 
that it may fit the part perfectly, and which need uot be thicker 
than blotting paper, has become firm, a long stocking is drawn 
over it and is attached to the body clothing. At the end of a 
week the bandage is removed. The leg and foot are gently bathed 
with alcohol, thoroughly dried, powdered, and protected as before, 
and the bandage is again applied. At this second dressing the 
irritable adducting muscles, after the interval of complete rest, 
will be much less active and the contracted tissues will be less 
resistant, so that the foot may be easily turned somewhat out- 
ward or beyond the line of the leg. 

After four or five applications of the bandage, at Aveekly inter- 
vals, the foot, in ordinary cases, can be held without resistance 
in the attitude of extreme equinovalgus. The sole, which at 
first looked backward, inward, and upward, will be turned in the 
opposite direction, forward, outward, and downward, and the 
inner border of the foot, which was concave, is now convex 
_r. 440). When the varus has thus been overcorrected, treat- 
ment is directed to the secondary equinus. At this stage it is 
well to cover the bottom of the foot with a foot plate of thin 
wood (splint wood or cigar-box cover) to give the plaster bandage 
more solidity, and in order that its pressure may aid in flattening 
the rounded sole. At first one carries the foot upward (toward 
dorsal flexion), while it is still retained in the abducted position, 
hut when the right-angled attitude has been attained it is brought 
nearer to the axis of the leg. The everted position, or the 
attitude opposed to varus, is retained, however, until correction 
i- completed. In correcting the equinus a certain amount of 
force i- required, -uilieient to cause some discomfort during the 
application of the placer, but not sufficient to occasion suffering 
afterward. The force Is applied by means of the sole plate to 
the entire foot, so that the posterior extremity of the os calcis 
may he drawn downward l»y actual lengthening of the tendo 
Achillis, and not, a- ie often the case, by an overcorrection of the 



DEFORMITIES OF THE FOOT. 



753 



forefoot, while the heel remains in its original position of plantar 
flexion. By the proper application of force the eqninns is gradu- 
ally overcome ; the sharp indentation or fold at the insertion of 
the tendo Achillis is lessened, and the heel becomes more 
prominent. 

The reduction of the equinus may be somewhat more difficult 
than that of the varus, but it should be entirely corrected in 
three or four months from the time of beginning the treatment. 
As has been stated, correction of the deformity implies [overcor- 

FlG. 450. 




The first application of the plaster bandage, showing the improved position. 
(Compare with Fig. 444.) 



rection (Fig. 439) ; and it is well, when this lias been attained, 
to hold the foot for several weeks, by means of the plaster 
bandage, in an attitude of extreme pronation and dorsal flexion 
(calcaneovalgus ) in order to impress, as il were, the new position 
upon it- structure. This concludes the first stage of the treat- 
ment, the simple rectification of deformity. 

Correction by the plaster b;md;iL r <- has the great advan 
of placing the treatment entirely under the control of the sur- 
geon. When properly applied, tie- support lit- perfectly, it is 



;:, 1 ORTHOPEDIC SURGERY. 

light and clean, and it holds the foot in the desired attitude with- 
out undue pressure. 

The disadvantages of the treatment are due almost entirely to 
its improper application. For instance, the bandage may be too 
heavy, or the padding may be so thick that it does not retain its 
position. Excoriations arc usually due to carelessness in the 
application of the bandage, or because it is not removed in 
proper season. The fear of compression, of atrophy of muscles, 
of stunting the growth of the limb is groundless. At the end of 
the plaster-of-Paris treatment, the corrected foot is, as a rule, 
larger than one that has remained untreated. The stunted foot 
i- the result of non-treatment, or of ineffective treatment by 
braces or otherwise ; not of the enforced rest necessitated by the 
proper reduction of deformity. 

The Rectification of Deformity by Splints and Braces. Of 
mechanical supports there are many varieties. Complicated 
appliances should be avoided because they are unnecessary and 
because they serve to distract attention from the prime object of 
treatment, the rapid and systematic correction of deformity. Of 
the simpler braces that used by Judson is one of the best and 
will serve as a type to illustrate this form of treatment. The 
method of application may be described in Judson's own words : 
" The apparatus which I have conveniently used to effect this 
reduction before the child learns to stand is a simple retentive 
brace which acts as a lever, making pressure on the outer side 
of the foot and ankle at A, in Figs. 451 to 454, inclusive, and 
counter-pressure at two points, one on the inner side of the leg 
at B, and the other at the inner border of the foot at C. It is 
advisable to keep in mind that this simple instrument is a lever, 
because if we know that we are using a lever with its three well- 
defined points of pressure we can make the apparatus more 
efficient than if we view it, in a more general way, as an apparatus 
for giving a better shape to the foot. 

" I use a little brace made of sheet brass, doing the work with 
a few simple tools. An advantage of doing the work one's self 
ig that then- is no room for doubt as to where the blame lies if 
the apparatus does not wort well. Two curved disks, B and C, 
Figs. 153 and lo I, an- riveted to a shank, D, and thus is formed 
th.it part of th<' brace which applies the two points of counter- 
pressure; while, on the other hand, the point of pressure is 
brought into action by a third disk or shield, A, which is drawn 
tightly againsl the outer side of the foot and ankle, and held in 



DEFOEMTIES OF THE FOOT. 



755 



place by a strip of adhesive plaster, E, which includes the leg 
and the piece which connects the two disks, B and C. The disks 
are lined with two or three thicknesses of blanket, easily renewed, 
when necessary, with a needle and thread. These braces are so 
cheap and easily knocked together that it is nothing to apply 
new and larger ones, using heavier material for the shank as the 
child grows. In general, three sizes will be enough, the shanks 
being 12 gauge, f in. wide; 14 gauge, J in. wide ; and 16 gauge, 
f in. wide. The disks are conveniently made from 22 gauge, 
1J in. wide. The rivets are copper belt rivets, No. 13. A lip 
turned on the edges of the disks, with the flat pliers, gives 



Fig. 451. 
B« 



Fig. 452. 



Fig. 453. 



Fig. 454. 




Fig. 455. 



Fig. 456. 



Fig. 457. 



Fig. 458. 



to 



lb 



01 





The Judson club-foot splint and its application. 



stiffness to the thin brass and protects the skin from the rough 
edge. If more easily obtained, tin disks, light bars of iron or 
steel, and ordinary iron rivets would doubtless answer. 

" The brace is applied with three strips of adhesive plaster. 
The upper and lower pieces, F and G, Fig. 154, arc -imply to 
keep the apparatus in place, which they do effectively it' ordinary 
gum plaster la used ; while by drawing the middle strip, E, tightly 
over the shield, and straightening the brace from time to time, 
the deformity is gradually and gently reduced. At each reappli- 
cation the brace is made a little straighter than the fool at thai 



756 ORTHOPEDIC SURGERY. 

stage. This may readily be done by the hands, and then the 
adhesive strip is to be tightened over the shield until the shape of 
the fool agrees with that of the brace. After a few days the brace 
is to be made still straighter and again reapplied, and made tight 
until another point of improvement is gained. The brace is applied 
very crooked at the beginning of treatment, as in Figs. 453 and 
154, and is straightened from time to time, and a longer brace 
applied as the deformity is reduced and the patient grows. It 
-lion Id be removed every week or two weeks, and an interval 
of a few days allowed for freedom from the brace, when the 
mother is advised to manipulate the foot constantly, using as 
much force as she will in the direction of symmetry. Manipu- 
Iating the foot during these intervals is of great importance, as 
cases have occurred in which varus and equinus have been entirely 
overcome by the mother's hand alone. 

" Bv this simple and prosy treatment, carried out systematically 
and without haste, or violence, or pain, the foot, unless it is a 
frightful exception, may with certainty be changed from varus to 
valgus. At the same time the tendo Achillis is lengthened until 
the position of the foot is near the normal, or at right angles 
with the leg, as the result of manipulation and giving the brace 
from time to time a partly anteroposterior action. Figs. 453 and 
1") 1 show approximately the shape of the brace at the beginning 
of treatment ; Figs. 455 and 456 when the varus is reduced, and 
Figs. 457 and 45-S when valgus has taken the place of varus. 
The foot, in this latter stage, may not hold itself valgus when 
left to itself, but with almost no force and with one finger it may 
!><• poshed into valgus." 

When the varus deformity is reduced the equinus is gradually 
corrected by carrying the splint behind the internal malleolus ; 
and, finally, if accessary, direct upward pressure may be applied 
by Lengthening the brace and applying it to the posterior aspect 
of the foot and leg. It may be noted that manipulation and 
stretching tin- contracted parts when the brace is removed is of 
much importance in the correction of deformity by this or other 
means. Splints of wood, tin, felt, and the like may be employed, 
hut they present no particular advantage over that which has 
been described. 

Tenotomy. The equinus lias been spoken of as the secondary 
deformity, but it- complete correction is often more difficult than 
that of varus. The mechanical stretching of the contracted parts 
by means <>f tin- plaster-of-Paris bandage or the brace is often 



DEFOE MITIES OF THE FOOT. -;>; 

accomplished with ease ; but in many instances time will be 
gained, after the foot has been forced into the position of equino- 
valgus, by the division of the tendo Achillis, which is the most 
resistant of the shortened tissues. After division of the tendon 
it is often necessary to use considerable force to stretch the other 
contracted parts, and to force the foot up to the limit of normal 
dorsal flexion, which is the object of the operation. Occasionally 
the obstacle seems to be in the posterior ligament of the ankle, 
and it is sometimes of service to reinsert the knife and to divide 
this structure, in part at least, so that it will give way under 
manipulation. When the foot has been forced into the posi- 
tion of overcorrection it is fixed in a plaster bandage, which 
is allowed to remain for several weeks, until the interval be- 
tween the separated ends of the tendon is filled in with the new 
tissue. 

In many instances the leg is rotated inward upon the thigh, 
and the habitual attitude is accompanied by accommodative 
changes in the ligaments of the knee-joint. During the rectifi- 
cation of the club-foot this secondary distortion may be, in part 
at least, corrected by forcible manual rotation of the leg outward 
on the thigh several times daily. 

Recapitulation. The management of the first stage of the 
treatment of infantile club-foot is, then : manipulation of the 
foot by the nurse from birth until systematic rectification can be 
begun ; mechanical correction, first of the varus and then of the 
equinus deformity, terminating with a period of retention in the 
overcorrected position (calcaneovalgus). Division of tendons, 
other than the tendo Achillis, is not often necessary. The time 
required for the completion of the first stage of the treatment, or 
overcorrection of deformity, should not, under favorable condi- 
tions, exceed three months. 

The rapid correction of deformity in the manner described, 
begun as early as possible and accomplished as quickly aa pos- 
sible, cannot be too strongly urged. In the first months of life 
the tissues are not resistant, the bones are practically entirely 
cartilaginous, and when the foot in its external appearance ifl 
rectified the rapid growth in the first months of life will change 
the interna] structure to conform to the normal condition-. The 
fear of atrophy, compression, or other harm from the temporary 
fixation necessary during rectification is groundless, and, in 
fact, exercise, so-called, except in the direction opposed to 
deformity, is harmful rather than beneficial. 



758 ORTHOPEDIC SURGERY. 

Correction of deformity may be accomplished by holding the 
foot in an improved position by strips of adhesive plaster, or by 
tlic clastic traction of rubber bands attached to the leg and foot. 
La compared with the case, rapidity, and certainty of correction 
by means of the plaster bandage such methods are uncertain and 
ineffective, and they will not therefore be described in detail. 

The Second Stage of Treatment. Support and Restoration of 
Function. When the deformed foot has been corrected, in the 
sense that all normal motions can be carried out by passive force, 
the first and most difficult part of the treatment will have been 
completed, and, in some instances, the deformity is actually cured. 
Such a result is unusual, however, for although the foot may be 
normal in appearance, its muscular balance has not been restored. 
This is shown by the fact that when support is removed the foot 
usually hangs downward and inward, and there is little apparent 
power in the dorsiflexors and abductors to, draw it upward and 
outward. If at this stage treatment were abandoned the defor- 
mity would almost invariably recur, at least in part. For this 
reason the foot must be supported in proper position until the 
slack of the lengthened tissues has been taken up by development 
in the normal attitude, aided by massage and stimulation of the 
muscles. Practically, support is always necessary until the child 
has begun to walk. 

The Retention Brace. The form of retention brace will 
vary somewhat according to the indications of the individual case. 
The object is to hold the foot in what is called the overcorrected 
attitude — that is, dorsiflexion and eversion. This may be accom- 
plished by splints of pasteboard, leather, tin, and the like ; but a 
light metal brace provided with a sole plate and upright, as 
shown in Figs. 483 and 484, is preferable. The best support is 
the Taylor brace, the invention of Dr. C. F. Taylor, of New 
York (Fig. 450). This consists essentially of a light upright 
that extends along the inner side of the leg to the knee, and a 
thin steel foot plate of the exact size of the sole, with an upright 
flange on the inner side, rising to a point just above the dorsal 
surface of the foot, against which the foot is pressed closely, so 
that recurrence of the varus deformity is prevented. The joint 
at the ankle is provided with a catch that prevents plantar flexion, 
but allows dorsiflexion. By bending the upright and the sole 
plate the foot may be held in slight abduction and eversion. 
The apparatus Is applied with straps, as illustrated, and, if neces- 
sary, its position is further fixed by a band of adhesive plaster, 



DEFORMITIES OF THE FOOT. 



759 



applied on the inner side of the leg to hold the heel firmly 
against the foot plate. The foot is thus held constantly at a 



Fig. 459. 




The Taylor club-foot brace. 
Fig. 460. Fig. 401. 





Taylor club-foot brace, showing the method Of application and attachment. 



'60 



ORTHOPEDIC SURGERY. 



right angle to the leg, or, better, in the early stage of treatment, 

in an attitude of dorsiflexion and valgus. Occasionally, after 
complete rectification of the deformity, the foot still turns in. In 
most instances this is due to an inward rotation of the tibia on 
the femur at the knee-joint, but in some cases it is caused by a 
spiral twist of the tibia itself. In order to correct this secondary 
deformity an extension of the upright of the brace is carried 
beneath the leg, provided with a joint at the knee, and is extended 
up the outer side of the thigh. At the hip it is attached by a 
free joint to a padded pelvic band of light steel (Fig. 470). The 
hand holds the upright in the proper relation to the thigh; thus, 



Fig. 462. 



Fig. 463. 





The Taylor club-foot brace, showing the adhesive plaster, by means of which the heel is 
held down, and the method of attachment. This brace may be used to correct deformity as 
well as to retain the foot in proper position, as is illustrated by these figures. As a retention 
apparatus the foot plate should be held at a right angle to the upright by the stop-joint 
shown in Ki- 
lty twisting the part below the knee the foot can be rotated out- 
ward to the desired degree. In less marked cases the retention 
bands used for pigeon-toe may be employed (Fig. 426). 

Methodical Manual Correction. Several times during 
the day the bincc should be removed in order that the foot may 
be thoroughly massaged and forcibly turned, first toward valgus 
— that is, outward at the mediotarsal joint — so that the inner 
border is made convex, and then to the extreme limit of dorsi- 
flexion and abduction. If the leg is rotated inward it is forcibly 



DEFORMITIES OF THE FOOT. 701 

rotated outward on the femur. Even if the tibia is actually 
twisted ou its long axis, the influence of the brace and forcible 
manipulation will usually correct the deformity. Active contrac- 
tion of the weak muscles may be induced bv tickling: the sole of 
the foot or by the use of electricity, and, finally, the entire limb 
should be thoroughly massaged before the brace is reapplied. 

When the deformity shows no tendency to recur the brace may 
be removed for a part of the day ; later it is used only at night ; 
and, finally, it may be discarded if the child walks normally. 
But it is best to continue the daily manipulation, more particu- 
larly the systematic stretching or overcorrection of the foot, for a 
long time. Thus one may assure one's self that there is no 
tendency toward deformity, of which the first symptom is always 
a slight limitation of dorsal flexion and of abduction. 

In many instances the deformity may have been so thoroughly 
overcorrected by the plaster-of -Paris bandage or by the brace, 
and the after-treatment of massage and stretching may have been 
so efficiently applied by the nurse or parent, that the retention 
brace may be unnecessary. On the other hand, the inclination 
toward deformity may be so marked that a brace may be neces- 
sary to hold the foot in slight abduction and valgus for a year 
or longer. In other cases the use of a light brace to hold the 
foot in the overcorrected position during the night is alone required. 
These are points to be decided by the circumstances in each case. 
The period of observation and supervision is included in the final 
stage of the treatment. 

Third Stage of Treatment. Supervision. During this period 
the attitudes of the limb and foot of the walking child must be 
carefully watched, and particularly the signs of wear on the sole 
of the shoe. If it shows greater wear on the outer side than is 
usual it is an indication that the weight does not fall directly on 
the centre of the foot, and that there is, therefore, a tendency 
toward deformity. This must be counteracted by making tin- 
sole thicker on the outer side or slightly wedge-shaped, so that 
the weight may be deflected toward the inner border. 

This third period of treatment, or, rather, <>f oversight of the 
functional use of the foot, must !><• continued indefinitely. In 
fact, it is the quality of this final supervision thatdecidee in most 
instances whether the ultimate outcome is t<. be what i> called a 
satisfactory result or a perfect anatomical and functional cure. 

The Treatment of Neglected Club-foot, lie- treatment of 
club-foot under what may be called tin- proper conditions, as 



762 ORTHOPEDIC SURGERY. 

outlined in the preceding pages, applies practically to all cases 
before the completion of the first year of life, and mechanical 
rectification may be successfully employed in cases far beyond 
this limit of age. As a rule, however, when the patient has 
walked for any length of time, the resistance of the tissues has 
increased to such an extent that more rapid and effective treat- 
ment is indicated. The investigations of Wolff have shown that 
the internal structure of the bones corresponds to their external 
contour, and that the structure and contour are adaptations to 
functional use. This internal structure is not, however, perma- 
nent, but is readily transformed to conform to changes in form 
or function. If, then, the external contour of the club-foot were 
suddenly reversed, and if the foot were used in this new attitude, 
a transformation of the internal structure of the bones and at 
the same time of their shape would begin at once. This would 
continue until both structure and shape had become adapted to 
habitual function. It is upon this natural power of transforma- 
tion that one depends for the final and complete change of the 
distorted bones to the normal ; and what is true of a resistant 
structure like bone is equally true of the other constituents of the 
deformed foot. 

Age as Influencing Treatment. There is, then, this important 
difference between the indications for treatment in infancy and 
in childhood. In the first instance the foot has no essential 
function ; in the second the weight of the body and habitual use 
tend to confirm and to increase the deformity. If walking is 
permitted during the process of rectification of the foot it must 
necessarily retard its progress. As a general principle of treat- 
ment, functional use should not be permitted, therefore, until the 
weight of the body may aid rather than retard the correction of 
deformity. The great numbers of complicated and cumbersome 
machines that are shown in the older text-books were designed 
for the ambulatory treatment of club-foot; and admitting that 
such apparatus may be efficacious in the hands of one skilled in 
it- use, yet under ordinary conditions treatment by such means 
simply serves to fix rather than to correct the deformity. The 
most important function of the brace, aside from its use as a 
correcting appliance in early infancy, is to support the foot after 
deformity ha- been corrected and to guide it in its functional use 
until it- normal strength ha- been regained. And while rectifi- 
cation of deformity, eveD in adolescence, by simple mechanical 
means alone i- ]>o-~il>lc, yel only in exceptional cases would one 



DEFORMITIES OF THE FOOT. 



763 



be justified in selecting a tedious and uncertain treatment which 
offers practically no advantage over more rapid methods. 

The Rapid Correction of Deformity. The principles on which 
operative treatment should be conducted are the same that govern 
mechanical treatment. Thus, the deformed foot must be over- 
corrected, and it must be held in the overcorrected position until 
the immediate tendency toward deformity has been overcome. 
It must then be supported until the process of transformation of 
its internal structure is completed and until the balance of mus- 
cular power has been regained. Xo surgical operation, however 



Fig. 464. 




Reduction of the varus deformity. (Lorenz. 



radical, can be, in childhood at least, curative by itself alone 
Operative procedures are undertaken simply for the purpose oi 
accomplishing the primary overcorrection, and the operation 
by which this object can be attained with the least interference 
with the structure of the foot should be selected. Such an 
operation is what may be called forcible manual correction. 

Forcible Manual Correction. The patient having been anaes- 
thetized, one first attempts to correct the sharp inward twisf al 
the mediotarsaJ joint. Supposing the left font to be deformed, 
one gra-p- the heel with the right hand in such a manner thai 



'64 



mmiorhpic srjK.ERY. 



the projection or muscular part of the palm lies on the outer 
aspect <>f the foot against the most prominent part of its outer 
border, which is at the junction of the os ealcis and cuboid bones. 
This hand serves as a fulcrum over which the inverted foot may 
he bent. The forefoot is then grasped firmly by the left hand, 
ami one begins a series of outward twists over the fulcrum of the 
opposing palm, gently at first, with alternate relaxation of pressure, 
hut with gradually increasing force as the resistant tissues stretch 
under the tension. 



Fig. 465. 




Flattening the sole. (Lorenz.) 



If greater force is required, a triangular block of wood, well 
padded, may be used as the fulcrum (Fig. 464), one hand pressing 
on th<- heel and the other on the forefoot; but there is a great 
advantage in using aothing but the hands, because one feels sure 
that no injurious force is likely to be exerted. Under this steady 
manipulation the foot sood Loses its rigidity and its elastic recoil 
toward deformity; it becomes so limp that with two fingers one 
cai t only hold the sole straight, but can push it or bend it 



DEFORMITIES OF THE FOOT. 



765 



outward. Thus the first stage of the methodical correction has 
been accomplished. 

One then turns his attention to the supination or inversion of 
the sole, which makes the outer border of the foot lower than 
the inner border. The leg is grasped firmly near the ankle with 
the left hand, and with the right the foot is forcibly twisted in a 
direction downward, outward, and upward, over and over again, 
with steadily increasing force as the tissues slowly yield, until it 
may be forced into a position of extreme abduction, so that the 



Fig. 466. 




Reduction of the equinus deformity. (Lorenz 



sole may be made to look outward and downward — the reverse of 
the former attitude (Fig. 384). 

One next stretches the contracted plantar fascia and reduces 
the cavus which i- usually present by forcing tin- forefoot toward 
dorsiflexion, against the resistance of the contracted tendo A.chillis, 
until the sole i- made perfectly flat (Fig. 165). Finally, the 
fourth, and often the most difficult part of the rectification — that 
of forcing the displaced astragalus into its proper position between 
the malleoli— is attempted. To accomplish this thetendo A.chillis 
is first divided subcutaneously, and, if accessary, the posterior 



766 ORTHOPEDIC SURGERY. 

Ligament of the ankle is also divided at the same time. The 
patient is then turned upon his face so that with the knee resting 
on the table the leg is held upright. This allows one to hook the 
fingers about the extremity of the os calcis, while the hand and 
arm. Lying along the sole of the foot, may be used as a lever to 
force it toward dorsal flexion as the os calcis is drawn down- 
ward. In this manner forcible stretching is continued until the 
dorsum of the foot can be brought almost into apposition with 
the crest of the tibia. When the operation has been completed 

Fig. 467. 




Untreated club-foot, showing the secondary knock-knees. (See Fig. 468.) 

the foot should be perfectly limp. It is usually somewhat con- 
gested from the pressure of the fingers, but it is warm and the 
circulation i- unimpaired. 

( )ne may assume that in the change that has taken place from 
rigid deformity to a Limp foot that can be moulded into the 
desired shape the component parts of the deformed foot must 
have been subjected to considerable violence; that ligaments and 
muscles musl have been stretched and, it may be, ruptured; 
that uew surfaces are now apposed to one another in the articu- 
lation-, and that the hones have been forced into approximately 



DEFORMITIES OF THE FOOT 



767 



normal position. This method of treatment has a great advantage 
over the ordinary operative treatment in that the entire foot par- 
ticipates in the correction instead of a limited portion, as when, 
for example, bone is removed by cuneiform osteotomy. It has 
a second and almost equally important advantage in that the 
immediate use of the corrected and yielding foot is possible in 
the place of the necessary rest that must follow cutting opera- 
tions. For these reasons forcible massage should be the operation 
of choice, and preliminary, at least, to more severe procedures 



Fig. 468. 



Fig. 469. 




After forcible correction. Compare with 
Fig. 467. 



The attitude of overcorrection, in which 
the feet are fixed after the operative treat- 
ment, the plaster bandage extending only 
to the knees. 



in the treatment of resistant club-foot in childhood. The only 
disadvantage of the operation is the actual labor which it neces- 
sitates on the part of the surgeon, usually twenty minutes or 
more of rather exhausting work. 

The foot must now be fixed by a plaster bandage in an over- 
corrected position. It is first evenly covered with a layer ol 

cotton and a broad bandage of canton flannel, and while it LS held 

by the assistant the plaster bandages are applied from the tips of 

the toes to the upper part of the thigh. It Is important that the 



768 ORTHOPEDIC srildERY. 

toes should not project beyond the bandage because of the swell- 
ing that sometimes follows. It is important, also, that the foot 
should be held in the proper position while the bandage is harden- 
ing, and that it should not be manipulated to any extent after 
the bandage is applied, in order that no rigid wrinkle may press 
againsi the skin. The bandage is applied above the knee in 
order that the tibia may be rotated outward to its normal position 
and held there, and because more effective fixation may be assured 
and greater pressure exerted on the foot in walking. To utilize 
this pressure to better advantage the bandage should be made 
very thick beneath the sole, and a thin foot plate of wood may 
he incorporated in the plaster if due care is taken to prevent 
pressure on sensitive points. When the bandage is applied the 
position of the foot should be that of overcorrection of deformity, 
flexed beyond the right angle, twisted far outward, and the outer 
border should be elevated considerably beyond the level of the 
Inner border (Fig. 468). 

One would suppose, after using the force that has been neces- 
sarily applied, that much pain and swelling would follow. This 
is, however, not usually the case. Often, on the following day, 
the patients are able to stand upon the foot, and always within 
the first week if the bandage has been properly applied. The 
pain following this operation is far more often caused by pressure 
of an ill-fitting bandage than by the violence that has been used. 
Thus one should be careful to remove sections of the bandage 
if it appears to cause undue discomfort. These points are usually 
the front of the ankle, the back of the heel, and the inner border 
of the great toe. 

The Importance of Functional Use. The immediate use of the 
foot i- encouraged, in order that the weight of the body falling 
on its yielding structure may still further correct the deformity. 
Although only the heel and inner border bear weight directly, 
yet the pressure of the plaster sole on the parts that do not come 
in contact with the floor is usually sufficient to mould the foot 
into it- proper shape. If greater pressure is thought to be neces- 
sary, wedges of wood or cork may be attached to the sole of the 
plaster bandage, so that all parts may bear weight equally. The 
bandage is covered by a stocking ; a slipper may be worn indoors 
and an ordinary over-hoc for street wear. 

The first ham lain' Bhould be removed at the end of about four 
weeks, a- it will have become loose. The foot will then be found 
to be extremely flexible, and by an enthusiast it might be consid- 



DEFORMITIES OF THE FOOT. 769 

ered cured ; but knowledge of its previous condition should 
make it evident that a much longer time will be necessary to 
allow for its consolidation in the new position. At this time 
almost no evidence of the operation remains except, it may be, 
slight discoloration of the skin. The foot is again 'held as far as 
possible in the overcorrected position and another plaster bandage 
is applied, usually as far as the knee only. This is allowed to 
remain for from six weeks to six months, it being apparent, of 
course, that the longer the foot is fixed in the overcorrected 
position the less danger of subsequent relapse. The patient uses 
the foot constantly and is drilled in the proper method of walk- 
ing, so that the muscles of the limbs may become accustomed to 
the new and normal attitudes. , 

In most instances the plaster bandage is replaced, at the end 
of about three months, by a brace, to be worn inside the shoe, 
usually of the simplest description (Fig. 484), consisting of an 
upright bar with a calf band, attached to a steel sole plate by a 
joint that will permit dorsal flexion but checks extension at a 
right angle. This is applied because the dorsal flexors, after 
years of disuse, only slowly recover sufficient power to resist the 
action of the opposing group and the force of gravity. 

The second stage of the treatment is now begun. This may 
be divided into a period of active treatment and one of super- 
vision. The first, or treatment stage, consists in massage of the 
entire leg and of the foot to stimulate the growth of the atrophied 
muscles, and methodical manipulation of the foot several times 
a day. The important point in this manipulation is to force the 
foot with the hand to the extreme of the range of motions possible 
immediately after the operation, viz., eversion, abduction, and 
dorsal flexion, in the same order as at the time of operation. 
At the same time the patient attempts voluntarily to carry out 
these motions by his own muscles, the power being supplied by 
the hand of the manipulator. Slowly the muscles gain in 
strength and ability, and when normal muscular power and bal- 
ance have been regained the patient is practically eared. I Jut 
for a long period supervision of the patient's attitude, <>f the 
manner of using the font, of the wear of the sole of the shoe 
and the like must be exercised if one aim- to restore its normal 
appearance and function. 

One cannot exaggerate the importance of this after-treatment 
and of supervision, at Least, on tin- part of the surgeon. The 
active treatment may often be left to the parents. Bu< constant 

19 



'0 



ORTHOPEDIC srildERY. 



Fig. 170. 



oversight is necessary to make this after-treatment, which seems 
90 commonplace and simple, effective, and to assure one's self 
that the range of motion regained by the operation does not 
gradually become more and more restricted, even though the 
contour of the foot appears to be normal. 

Forcible manual correction may be employed with advantage 
from the second to the tenth year, although the limits may be 

extended in either direction in 
special cases. In this operation, 
as described, the tendo Achillis 
is the only structure divided. 
There is no particular objection 
to subcutaneous division of other 
tendons or ligaments in connec- 
tion with forcible manual correc- 
tion ; but for such prolonged 
manipulation it is much better if 
the skin, which itself must be 
stretched, is unbroken and dry 
rather than moist from the bleed- 
ing from punctured wounds. For 
this reason it is well to correct 
the deformity without extensive 
tenotomy if possible. 1 

Secondary Deformities. In cases 
such as have been described sec- 
ondary distortions of the limb 
are often present. Knock-knee 
rarely requires other treatment 
than daily manual correction in 
connection with the massage of 
the foot and leg. Hyperextension 
at the knee will correct itself 
during the treatment of the foot, 
which, being fixed in an attitude 
of dorsal flexion, obliges the pa- 
tienl to bend the knee habitually in walking. Inward rotation 
of the leg upon the thigh [soften present. This may be overcome 




The Taylor club-foot brace, with pelvic 
band, to prevent rotation of the leg. The 
brace is shown before the covering and 
straps are applied. 



Ible manual correction appears to have been described first by Delore. Lorenz em- 

- ipplemented in the older cases by the use of his osteoclast, to the exclu- 

:'tifa!ly, of all other treatment. (Heilungdes Klumpfusses durch das modellirende 

Redressernent. Wiener Klinik, November, 1895.} For this reason it is sometimes called the 

reatment. The method that has been described has been employed by the author 

for many year-. 



DEFORMITIES OF THE FOOT. 771 

by methodical manipulation and by the use of a brace attached to 
a pelvic band (Fig. 470). 

In many instances, particularly in childhood and adolescence, 
the patient has so long walked with exaggerated outward rotation 
of the femur that after correction of the deformity no inward 
rotation of the foot appears, even though inward rotation of the 
tibia be present. In other cases the inward rotation of the foot 
is caused by a failure to completely replace the astragalus between 
the malleoli. Occasionally the tibia is actually twisted on its 
long axis, so that an osteotomy may be required in order to over- 
come the deformity. 

Malleotomy. In confirmed club-foot, of the type under con- 
sideration, the chief obstacle to perfect correction is often the 
astragalus. This is displaced forward, downward, and inward, 
only the posterior portion of its articulating surface being con- 
tained between the malleoli. Thus the space between the two 
bones may have become insufficient for the anterior and wider 
part of the body of the astragalus. In such cases, even after 
division of the tendo Achillis and the posterior ligament of the 
ankle, dorsal flexion still remains restricted, and examination 
shows that the astragalus still projects as before, even though the 
foot has been forced into a position of apparent dorsiflexion and 
abduction. This apparent correction is the result of overcorrec- 
tion at the mediotarsal joint, of outward rotation of the tibia upon 
the femur, and of backward displacement of the fibula. 

In such instances the malleoli may be separated from one 
another by dividing the ligaments that hold them in apposition. 
A -traight incision about two inches long is made directly over 
the anterior aspect of the articulation, the Ligaments arc divided, 
and by inserting a thin chisel the bones are pried apart, while 
the astragalus is replaced in the proper position. This is usually 
easy if the restraining tissues on the posterior part of the ankle 
have been divided. The wound is then closed and the foot held in 
the overcorreeted position by a plaster bandage. Complete correc- 
tion of the varus deformity should, of course, precede this operation. 

It might seem on first consideration that if immediate correc- 
tion of deformity can be accomplished 30 easily in the confirmed 
cases it should be employed even in infancy. There are, bow- 

r. practical reasons against it : First, because the fool i 
-mall that it cannot be easily manipulated ; second, because even 
after it i- corrected it must !><• supported until the child begins 
t<» walk ; and, third because the foot can be so readily straightened 



772 ORTHOPEDIC SURGERY. 

without operation, which, even of so slight a character, is some- 
time- the cause of much anxiety to the parents. For these reasons, 
although immediate reduction of deformity is a thoroughly prac- 
tical and safe operation, it is usually postponed until a later time. 

Subcutaneous Tenotomy. The division of tendons and other 
tissues by the subcutaneous method has been mentioned incident- 
ally, but as it has so long occupied an important and even at one 
time the most important place in the treatment of club-foot, the 
operation and its effects may be described somewhat in detail. 

Tenotomy, as has been stated, is performed for the purpose of 
removing an obstacle to the correction and overcorrection of 
deformity. In the acquired or paralytic form of talipes one 
<>r more shortened tendons may be the chief obstacles to reposi- 
tion ; but in the congenital form, in which all the tissues have 
grown into deformity, the shortened tendons are by no means the 
only resistant parts, and tenotomy should be considered, there- 
fore, merely as an incident in correction. In the ordinary treat- 
ment of infantile club-foot tenotomy may often be dispensed 
with, and in the great majority of cases division of the tendo 
Achillis is alone required. 

When the tendon has been divided the deformity is immedi- 
ately overcorrected ; thus the two extremities are separated to 
the extent necessary to allow the improved position. At the end 
of three weeks or more, or at the time when the first plaster 
bandage is removed, the space will be filled with new material, 
and in another month the splice, which will be somewhat larger 
and thicker than the normal, should be strong enough for use. 
The slight thickening at the site of the operation may be felt for 
a year or more, but for all intents and purposes the new and 
lengthened tendon is perfectly normal, as is the function of the 
muscle of which it is a part. 

The process of repair is somewhat as follows: Immediately 
after the operation the space between the divided ends of the 
tendon i- filled or partially filled with blood; then leucocytes 
appear, which, with those in the blood clot, serve as pabulum 
for the plasma cells which migrate from between the fasciculi of 
the tendon and from the tendon sheath. The fibrin and red cor- 
pusclesof the dot are absorbed ; the extremities of the divided 
tendon -often and become fused with the new material, which 
begins t<» take on the form and consistency of true tendon and 
to separate itself from the adherent sheath. This new tendon, 
differs from the normal structure in that the fibrous fasciculi 



DEFOBMITIES OF THE FOOT. 773 

are more irregular and its substance is more like scar tissue, but 
practically it is perfectly normal in its appearance and function. 1 

Since the tendon sheath serves an important purpose in repair, 
it should be disturbed as little as possible. For this, as well as 
for other obvious reasons, subcutaneous tenotomy of the tendo 
Achillis, which is so prominent and so distinct from other 
important parts, is to be preferred ; but if more extensive division 
of other tendons is required the open operation is often indicated. 

Division of the Tendo Achillis. For this operation anaesthesia 
is usually required, preferably by means of nitrous oxide gas ; and 
it is hardly necessary to state that surgical cleanliness, even in 
so slight a procedure, is essential. 

The instrument should be small and very sharp, so that no 
force is required in the operation ; the blade should be as long as 
the tendon is wide. The patient is turned upon the side or to 
the prone position, so that the foot may be held with the heel 
upward by the left hand. The position and size of the tendon 
is ascertained by careful palpation, and the knife is then inserted 
to its inner side, at about the level of the extremity of the 
internal malleolus. The flat surface of the blade is held parallel 
to the tendon, and it is passed beneath it until its point can be 
felt beneath the skin on the opposite side. The edge is then 
turned upward and the tendon, being made tense, is divided by a 
sawing motion of the knife. When the division is complete, as 
indicated by the separation of the divided ends, the knife is with- 
drawn, and the minute opening in the skin, from which there is 
usually slight bleeding, is covered with a pledget of aseptic 
cotton. The foot is forced into dorsal flexion and is securely 
fixed by a plaster bandage. In applying the dressing one should 
take care that no pressure is brought upon the seat of operation, 
as this might interfere with the effusion of plastic material. As 
soon as the discomfort attending the operation has subsided the 
patient is encouraged to stand and to walk. Functional use 
stimulates the circulation, and, far from retarding repair, it is in my 
experience an important agent in assuring firm and rapid union. 

The Open Method. The tendon may be exposed by a long, 
vertical incision ; it is then split for a distance of two or three 
inches, and the division is completed at the upper and lower ends. 
Th<- two halves are then allowed to -lido by one another until 
the neces-ary elongation has been obtained. These an- then 
-utured to one another. 

" R. Seggel. Beitrage zur klin. Chir., 1903, Band xxxvii. - 



774 OB TH OPE DIC S UR GER Y. 

Theoretically j this operation, which assures union at a point 
of Beleetion, is safer than the subcutaneous method, in which the 
ends of the tendon are separated from one another; practically, 
it is in tli is class of cases less satisfactory in its results than the 
subcutaneous method. 

Division of the plantar fascia is not infrequently necessary, 
and should be performed subcutaneously. The tenotome is 
inserted beneath the skiu at about the centre of the concavity to 
one or the other side of the central band of the fascia, which is 
divided by a sawing motion of the knife. The part is put upon 
the stretch, and other resisting bands to the outer and inner side 
are divided in the same manner ; the cavus is then corrected by 
manual or instrumental force. The operation, like that upon 
the tendo Achillis, is practically free from danger. 

I >i vision of the tibialis anticus is not often necessary, as this 
tendon offers little resistance to the rectification of deformity of 
the ordinary type. 

The tendon of the tibialis posticus may be divided together 
with that of the tibialis anticus near the points of attachment. 
If the operation is required it may be combined with simulta- 
neous section of the calcaneonavicular ligament, with which are 
blended the anterior part of the deltoid and fibres of the anterior 
ligament of the ankle. According to Parker's directions, the foot 
should be strongly abducted to make the parts tense. The tenotome 
is entered directly in front of the anterior border of the internal 
malleolus, its cutting edge being turned forward between the skin 
and the ligament. It is then turned toward the ligament, and 
the tissues are divided to the bone. The blade is then made to 
enter the interval between the astragalus and the scaphoid, and 
i- carried downward and forward to divide the inferior part of 
the ligament and at the same time the tendons of the tibialis anticus 
and posticus. 

The posterior ligament of the ankle-joint may be divided or 
sufficiently weakened so that it may be ruptured after section of 
the tendo Achillis by passing the knife directly downward in the 
middle line upon the upper border of the astragalus. 

The Correction of Confirmed Club-foot by the Method of 

Julius Wolff. 

Wolff's treatment of club-foot, as described by Freiberg, a 
former assistant in his clinic, may be summarized as follows: 1 

I M'dica! News, October 29. 1892. 



DEFORMITIES OF THE FOOT. 



775 



Fig. 471. 



The patient is anaesthetized, and with the hands and by the use 
of a moderate amount of force the deformity is reduced as far as 
possible. The foot is held in the improved position by means of 
strips of adhesive plaster passing from the dorsal surface of the 
inner border of the foot under the sole and up to the outer aspect 
of the leg. The leg and foot are then covered with cotton from 
the tuberosity of the tibia to the tips of the toes, and a plaster 
bandage is applied. As the plaster is hardening the position of 
the foot is still further improved by pressing the heel inward and 
the forefoot outward and upward. Two fenestra are cut in the 
plaster at the points of greatest pressure — one over the external 
surface of the ankle and the other over the 
internal surface of the great toe. If tenot- 
omy is considered necessary it is usually 
performed as a preliminary operation several 
days before forcible correction. 

On the third or fourth day after the oper- 
ation a wedge-shaped section is cut from 
the bandage on the outer side of the ankle- 
joint and a linear division is made about 
the ankle, so that the leg and the foot parts 
of the bandage are separated (Fig. 471). 
The leg being held firmly, the foot is forced 
outward and upward to the extent that the 
wedge-shaped opening on the plaster will 
allow, and the two sections are then united 
by a covering of plaster bandage. For the 
secondary correction anaesthesia is not re- 
quired. At intervals of several days larger 
wedges are removed, and the manipulation 
is repeated until the patient stands with the foot in a satisfactory 
attitude; that is, in pronation, abduction, and dorsiflexion. If 
the deformity is extreme the bandage may be reapplied before 
the correction is completed with advantage. One should take 
care that the toes are not compressed, but lie on the same plane 
in normal relation to one another. 

When rectification is complete the plaster bands ivered 

with stripsof pine shavings, held in place by a crinoline bandage, 
and painted with carpenter's glue. When this is hardened the 
whole ia covered with a thin silicate bandage ; over tin- the shoe is 
fitted and the patient i- encouraged to walk. This form of dress- 
ing i- used until the transformation of the deformed part- may 




The points at which the 
bandage is divided and the 
wedge removed. (Freiberg.) 



776 ORTHOPEDIC SURGERY. 

be supposed to be complete, the time varying with the case, from a 
few months to a year. The time required for the primary cor- 
rectioD is from a week to a month. When the bandage is finally 
removed massage and exercises are to be employed. 1 

Wolff 's treatment is an efficient means of correction, although 
somewhat tedious. It may be more conveniently employed in 
later childhood and adolescence than at an earlier age. 



Fig. 472. 



Forcible Correction of Deformity by Means of Osteoclasts 

and Wrenches. 

In place of manual correction greater force may be employed 
by means of wrenches or osteoclasts to overcome the deformity. 

There is this important difference 
between the two procedures : 
force may be applied by the hands 
for as long a time as is necessary 
without fear of injury, while force 
applied by a machine must be 
momentary because of the press- 
ure and strain on the parts where 
the leverage is exerted. Manual 
force continuously applied may 
be supposed to stretch the re- 
sistant parts, and although much 
less power is exerted it is really 
more effective than the sudden 
and momentary force of the 
wrench or osteoclast, because it 
may be continued until the de- 
formity has been overcorrected, 
while complete correction by 
means of instruments may neces- 
sitate several operations. 

The Thomas Method. Of 
instrumental correction that by 
means of the Thomas wrench is 
one of the simplest and most 
efficient. The wrenching may or may not be preceded by ten- 
otomy, a point to be decided by the resistance of the parts. As 




The Thomas wrench as used in the correc- 
tion of clnb-foot. 



-r die Ureachen. das Wesen und die Behandlung des Klumpfusses. Julius Wolff 
Berlin, 



BEFOBJIITIES OF THE FOOT. 



777 



a rule, division of the tendo Achillis alone is necessary. The 
instrument is a simple heavy monkey-wrench, of which the jaws 
have been replaced by two strong pins slightly bulbous at the 
ends to keep the covers of rubber tubing from slipping off. 

The wrench is applied to the inner side of the foot and screwed 
down so that it may " bite " and hold its place firmly, for if it 
slips it is likely to abrade or tear the skin ; then with consider- 
able force the foot is twisted outward and upward (Fig. 472). 



Fig. 473. 




Resistant club-foot in later childhood. (See Fig. 474.) 



The "keynote" of the operation la to bo wrencb the foot that 
it loses its elasticity and shows no tendency to recoil toward 
deformity. The foot is then placed in the besl possible position, 
and is retained then- by the Thomas foot splint or by a plaster 
bandage. In certain instances one may complete the rectification 
at one operation, but this is noi usually attempted, the procedure 
being repeated at intervals of a few days until the deformity bae 
been overcorrected. In very resistant ghl or ten applica- 

tions of force maybe y. When the deformity has 



77S oimiOPEDIC SURGERY. 

rectified the foot is beld in the ovcrcorrected position for several 
weeks by the splint or by the plaster bandage. 

A- a walking appliance a simple upright of iron with a calf 
band is applied to the inner side of the leg, from a point just 
below the knee to the heel of the shoe into which it is inserted, 
as i< the Thomas knock-knee brace (Fig. 343). By bending the 
upright the foot may be kept in slight valgus, and this position 
is still further assured by making the outer side of the sole of 
the shoe thicker than the inner, so that the weight falls upon the 
inner border of the foot. In many instances the walking brace 
may be dispensed with in the after-treatment, but a light brace 
is usually worn to hold the foot in the corrected position during 
the night, until the power of the abductors and dorsal flexors has 
been regained. Massage and manipulation are used in the after- 
treatment in the manner already described. 

AY hen properly applied the treatment is satisfactory and free 
from danger. Sloughing of the tissues caused by the pressure 
of the instrument or by the plaster bandages has been reported, 
but such accidents have not occurred in the extensive practice of 
Thomas and Jones. 

Correction by Means of the Osteoclast. The late Mr. 
Grattan, of Cork, used the osteoclast that goes by his name 
(Fig. 346) to crush and to overcorrect resistant club-foot. The 
operation may include besides the correction of the deformity of 
the foot itself fracture of the leg above the malleolus, to turn the 
foot toward valgus, and a second fracture half-way up the leg, 
to overcome the inward rotation or twist of the tibia. Mr. 
Grattan's results have been very satisfactory. Other appliances 
constructed on somewhat similar principles may be employed. 
Of these the Lorenz osteoclast 1 and the Bradford 2 lever apparatus 
are the most effective. 

The Open Incision Combined with Forcible Rectification of 
Deformity. Phelps' Operation. When extensive division of 
contracted parts is indicated the open incision is to be preferred 
because of the opportunity thus offered for the recognition and 
f<»r intelligent selection of structures that require division in the 
final correction of the deformity. 

Phelps 1 operation is essentially simply the division of resistant 
parts through an incision on the inner border of the foot, corn- 
Lined with sufficient force, manual or instrumental, to overcorrect 

1 Wiener Klinik, November, December, 1895. 2 Bradford and Lovett, 2d ed., p. 414. 



DEFORMITIES OF THE FOOT 



779 



the deformity It is the most conservative of the more radical 
procedures, and by it even the most severe type of deformity in 
the adult can be corrected; that is to say, the deformity may be 
overcome and a serviceable foot may be assured to the patient. 
Perfect functional cure is not possible when deformity has become 
habitual after many years of neglect. 

The steps of the Phelps operation are as follows : After proper 
surgical preparation the Esmarch bandage is applied. The tendo 
Achillis, and usually the posterior ligaments of the ankle, are 

Fig. 474. 



4 


I 


i 



The deformity (Fig. 473; corrected by Phelps' operation and by cuneiform osteotomy 
of the os calcis. 



divided subcutaneously, and by manual or instrumental force 
one attempts to correct the plantar flexion. An incision i~ then 
made on the inner border of the foot, just below and in front of 
the internal malleolus, which is extended directly downward over 
the head of the astragalus to include the inner quarter of the sole. 
Through the incision all resistant parts are divided in order, as 
stated by Phelps. 

1. The tibialis posticus, and theanticus if it offers resistance. 

2. The abductor hallucis. 
.'3. The plantar fascia. 



'SO 



ORTHOPEDIC SURGERY. 



4. The flexor brevis digitorum. 

5, The Long flexor of the toes. 

i). The deltoid ligament in all its branches. 

Daring the successive division of the tissues repeated attempts 
are made to correct the foot, and only those structures are divided 
that present themselves as tense and resistant tissues when the 
foot is forcibly abducted. 

In the adult type of club-foot no particular effort is made to 
recognize the different structures, but all the tissues on the inner 



Fig. 475. 




Resistant club-foot in later childhood. (See Fig. 476.) 

side of the foot, including bloodvessels and nerves, the deep liga- 
ments, and occasionally the tendon of the peroneus longus muscle, 
are divided. Even then it is necessary to apply considerable 
force to correct the deformity. In certain instances the rectifica- 
tion of deformity necessitates osteotomy of the neck of the 
astragalus or the removal of a cuneiform section from the os 
calcis. The object of the Phelps operation is, by division of 
resistant tissues and by the use of force, to overcorrect the de- 
form. <1 foot at one sitting, and as much force and as extensive 



DEFORMITIES OF THE FOOT. 781 

division of tissues as are required to accomplish this object should 
be employed by the operator. 

AVhen the foot can be held iu the desired position without 
resistance, the wound is covered with Lister protective, the foot 
and leg are thickly covered with gauze and cotton, a plaster 
bandage is applied, and the limb is elevated. The large gaping 
wound closes by granulation in from one to three months. The 
first bandage is usually changed at the end of a month, and the 
patient then begins to bear weight on the foot. 

By this operation the foot, even in severe cases in adult life, 
may be made straight in appearance. It is evident, however, 
that in such cases the correction of the deformity of the bones is 
by no means always perfect, for the forefoot may be simply 
twisted outward and upward, while the astragalus and os calcis 
may remain in an approximation to their original deformity. 
After thorough overcorrection by the Phelps operation the danger 
of recurrence of deformity in the adult and adolescent type of 
club-foot is not great, and in many instances support other than 
that of the plaster bandage for several months after the operation 
may be unnecessary ; but in childhood the ordinary precautions 
in after-treatment to prevent relapse will be necessary. 

Operations on the Bones. 

Osteotomy of the neck of the astragalus, as a supplementary 
part of the operation of forcible correction, has been mentioned. 
In certain instances, particularly in the adolescent or adult type 
of deformity, the displaced astragalus may offer such an obstacle 
to correction that its removal is indicated — an operation first per- 
formed by Mr. Lund, of Manchester. 

Astragalectomy. The astragalus, which in club-foot is displaced 
forward, may be removed easily by means of an incision passing 
over its most prominent part, in a direction forward and down- 
ward from the tip of the external malleoli^, between the tendons 
of the peroneus brevis and tertius. The soft parts are drawn 
aside, the ankle and astragalonavicular joint are opened, and tie- 
attachments to the scaphoid, and, as far as possible, those at the 
inner and outer border, are divided. The foot i- then addnoted 
so that the head of the bone may be seized with forceps and 
drawn upward, the interosseous Ligament and the internal lateral 
ligament having been divided with curved scissors, and the bone 
i- removed. If after removal of the astragalus the deformity 



782 



ORTHOPEDIC smoERY. 



cannot be corrected, the anterior part of the os calcis or the 
external malleolus should be removed as well. A useful movable 
foot may be obtained by this operation, but it by no means assures 
the patient from recurrence of deformity. It is never indicated 
as a primary operation, in childhood at least. The varus should 
be thoroughly corrected as a preliminary procedure ; then the 
resistance that the astragalus offers to dorsal flexion can be 
estimated (Fig. 476). 



Fig. 476. 



Fig. 477. 




After forcible correction and astraga- 
lectomy. (See Fig. 475.) 



Partially corrected club-foot, showing 
secondary knock-knee. 



Cuneiform Osteotomy. The removal of cuneiform sections 
of bone from the outer border of the foot is sometimes indicated 
when the deformity is of long standing, but the operation should 
1m secondary to other methods of correction. The aim should be 
to lengthen the cunt meted and shortened tissues on the inner 
border of the foot to the extent required for reposition, not to 
remove bone to accommodate these shortened tissues. If this 
has been shown to be impossible by ordinary means, then 
removal of bone may be indicated; but it is not often neces- 
sary in childhood or even in adolescence. If sufficient bone is 



DEFORMITIES OF THE FOOT. 783 

removed from the adult foot to permit complete correction of the 
deformity, relapse is not usual ; but in childhood, as has been 
stated, no operation will take the place of after-treatment. 

The treatment by cuneiform osteotomy as it is ordinarily car- 
ried out is sufficiently simple. In severe cases the astragalus is 
usually removed, and a wedge-shaped section of bone is taken from 
the os calcis, cuboid, and, if necessary, it may include the scaphoid 
bone also. The external malleolus may be removed if it inter- 
feres with reposition. Preliminary fasciotomies and tenotomies 
are usually performed, but those who favor this method of treat- 
ment rarely use force in reposition. If the deformity is less 
marked the astragalus is not removed, but a part of its body and 
neck is included in the cuneiform resection. The foot is retained 
in proper position until the wounds are closed ; then plaster ban- 
dages are employed for several months. Braces are seldom used 
in the after-treatment. 

Secondary Osteotomy. In certain cases of relapsed or in- 
effectively treated club-foot, even in childhood, deformity of the 
os calcis either interferes with correction of the foot or favors 
relapse. In such instances the removal of a cuneiform section of 
bone from the anterior extremity, as a supplementary part of 
overcorrection, may be of service. 

Simple Mechanical Rectification of Deformity in Walking* 
Children and in Later Years. 

It has been stated that simple mechanical rectification of de- 
formity was possible even in adolescence, but that the time 
required for such treatment, usually extending over several years, 
as a rule, excluded it from consideration. 

The simplest mechanical treatment is that by which the fool is 
slowly forced from equinovarns into equinovalgus by ;• brace on 
the lever principle, which is at first shaped to the deformity, and 
is then gradually straightened as the resistance diminishes. W hen 
the midpoint has been passed between varus and valgus the 
weight of the body aids in the correction of the remaining varus 
and equinus. The modification of the Taylor brace used byJud- 
son, an advocate of pure mechanics in the treatment of club-foot, 
will serve to illustrate the type of ;ij>|);ir;itu- which, with sligb.1 
change, may be employed to correct or to support the weakened 
or deformed foot. 

The brace consists of an upright, ;i flat, tapering bar of mild 



7-1 



ORTHOPEDIC SURGERY. 



Bteel, a fool plate of steel from 18 to 16 gauge, and a strong calf 
band. The shape of the brace, the method of its attachment to 
the leg by straps of webbing, and its effect in gradually changing 
the attitude of the foot from varus to valgus are shown in the 
accompanying figures. 

The upright is firmly riveted to the foot plate in the angle of 
deformity, so that the patient must walk upon his toes ; as the 
equinus is decreased by the influence of the weight of the body 
this angle is lessened (Fig. 480). 



Fig. 478. 



Q 



Fig. 479. 





The Judson brace. Fig. 478 shows the construction of the brace ; the foot plate, with the 
internal flange or " riser," the upright riveted to it, and the calf band. Fig. 479 shows the 
brace adjusted to fit the deformed foot. 



The important points are that the brace shall be strong 
enough to hold its place under the strain of use and that the 
foot shall be firmly secured to it, whether one or many straps of 
webbing are required, as maybe seen in the figures. The use of 
massage and manipulation is, of course, combined with the 
mechanical treatment. 

By persistent attention to the details of treatment satisfactory 
results can be obtained by this method in the less resistant cases, 
even in adolescence. 

Recapitulation of the Principles of Treatment of Congen- 
ital Talipes Equinovarus. The object of treatment is to over- 



T>EFOBMITIES OF THE FOOT. 



785 



come and to overcorrect the deformity at as early a period of life 
as is possible, and as quickly as possible. The object of over- 
correction is to overcome all the resistance of the tissues that may 
even in the slightest degree limit the normal range of motion in 
any direction. The foot must be fixed in the overcorreeted posi- 
tion until the recoil of the tissues toward deformity is no longer 
present. 

It must be supported in the proper relation to the leg, and 
at a right an^le with it, until the muscular balance has been 



Fig. 180. 



Fig. 481. 



Fig. 482. 






Showing the progressive reduction of deformity. Fig. 1*0 shows the ordinary attitude of 
the neglected club-foot in childhood with the adjustment of the brace, it being brut to 
accommodate the deformity. Fig. 481 shows additional details— an upright spur, useful in 
holding the heel and for the attachment of straps ; the spur of sheet brass thai may be bent 
over the gTeat toe to hold it in position. Fig. 482 shows other details in the method of 
attachment, a strip of adhesive plaster, with two tails in the place of the band of wrl.i.ing. 
This aids in fixing the heel. (See Figs. 483 and 484.) 



iblished by stimulation of the weaker and by Limitation <>f 
the activity of the stronger muscles, and until transformation of 
the internal structure has been completed. 

If efficient mechanical treatment i- ;t j ► j > 1 i « •< 1 at the proper time 
— that is to Bay, in earliest infancy — no operation other than 
division of the tendo Achilhs will !"• required. 

If the deformity La not corrected or i~ but partially com 
when the child begins to walk, some form of operation i-. 



'86 



ORTHOPEDIC SURGERY. 



rule, indicated ; but division of the resistant tissues must always 
be combined with the employment of sufficient force to accom- 
plish the desired result, viz., overcorrection of the deformity. 
Forcible manual correction, applied in the manner described, is 
the most efficient means of attaining this object. No instrument 
can equal the hand, and the force that can be applied by the 
hand is sufficient in all the ordinary cases in early childhood, and, 
in combination with subcutaneous division of the more resistant 
tendons and ligaments, even in later childhood and adolescence. 



Fig. 483. 



Fig. 484. 




Showing the progressive reduction of deformity, and illustrating the process of changing 
the shape of the brace from time to time until it holds the foot in valgus. (See Fig. 480.) 

Forcible correction by the Thomas wrench under the same 
conditions is an efficient treatment, but there is a manifest disad- 
vantage in submitting a patient to a succession of operations, 
even of SO slight a character, if immediate overcorrection can be 
attained l.y other means. 

The Phelps operation, which combines thorough division of the 
resistant parts with the application of proper force to overcorrect 
the foot, is the operation of selection for the more resistant cases 
in adolescence, in adult life, and in extremely resistant cases in 
childhood. 



DEFORMITIES OF THE FOOT. 787 

Astragalectomy and cuneiform osteotomy are never indicated 
as primary operations, but one or the other may be necessary for 
the complete rectification of the deformity when other means have 
failed. 

Complete cure of deformity, even in the later years of child- 
hood, is possible by means of braces alone, but such treatment is 
very tedious. It requires not only the continuous supervision of 
the skilled surgeon, but the intelligent and persistent co-operation 
of the parents. The results are in no way superior to those 
attained by more rapid methods, while the disadvantages of long- 
continued use of braces are sufficiently obvious. To the popular 
faith in braces as a cure-all of deformity, and to the unintelligent 
use of braces, may be ascribed now, as in former times, the 
failures in treatment of this eminently curable deformity. This 
statement seems justified even when balanced by the equally fal- 
lacious belief, so prevalent among physicians, that a radical 
operation, if it does not absolutely assure a cure, is, at least, the 
essential part of the treatment. 

Rectification of deformity, by whatever means, simply com- 
pletes the first stage of treatment. Perfect cure can only be 
assured by attention to the small details of after-treatment, by 
checking the slightest impulse toward deformity, and by guiding 
the unbalanced foot toward perfect functional use. 

Other Varieties of Congenital Talipes. 

Forms of congenital distortion of the foot other than equino- 
varus are not uncommon ; but, as a rule, these deformities are so 
slight and, as compared to equinovarus, so easily remedied that 
they are relatively of little importance. This distinction does 
not apply, however, to acquired talipes, which will be considered 
in the succeeding chapter. 

Congenital Talipes Varus. Eighty-five cases of simple varus 
are recorded in the table of statistics in a total of L660 congenital 
deformities of the foot. 

This deformity often appears to be an incomplete form of 
equinovarus, but in some instances tli<T<' i- simply ;> Blighl inward 
twist of the foot without supination (Fig. 425); in feet, the fore- 
foot is apparently drawn inward by the active movement of the 
great toe, which, in such cases, seems almost prehensile. (8ee 
Pigeon-toe.) in the more marked form tin- f<»«»t i- adducted and 
supinated, and the tissues are very resistant. 



7 s s ORTHOPEDIC SURGER Y. 

The slight grades of deformity may be treated by simple 
manipulation, and if deformity remains after the first year the 
shoe will, as a rule, correct it. The more marked varieties must 
be treated like the varus deformity of ordinary club-foot, by 
braces or by plaster, until the varus has been transformed into 
valgus. The after-treatment is the same as that for ordinary 
club-foot. 

Congenital Talipes Equinus. This is a rare congenital 
deformity, about half as common, according to the statistics, as 
varus (40 cases in 1660). The term equinus implies that dorsal 
flexion is limited, but that the foot is not deviated to one or the 
other side (toward valgus or varus). In congenital equinus the 
deformity is, as a rule, slight, and in many instances it may be 
overcome by gentle manual force applied frequently. In the 
more resistant type mechanical correction or tenotomy, followed 
by overcorrection and support, may be necessary. 

Congenital Talipes Calcaneus. Congenital calcaneus is com- 
paratively rare (28 cases in 1660). As a rule, the heel is 
prominent, the foot is habitually dorsiflexecl, and the dorsum can 
be easily brought into contact with the crest of the tibia (Fig. 
439). The exaggerated cavus that is usually present in acquired 
calcaneus is absent. Occasionally the deformity is accompanied 
by hyperextension of the knee ; and if, as in many instances, there 
is a history of breech presentation, it may be inferred that the 
attitude before birth was one of extreme flexion of the thighs 
upon the abdomen, the anterior surfaces of the extended legs 
being pressed closely to the ventral surface of the body, the feet 
being fixed in an attitude of dorsiflexion. As a rule, the defor- 
mity is slight, and the resistance of the tissues on the anterior aspect 
of the leg can be easily overcome by massage and manipulation. 
rhe foot should be gently forced toward plantar flexion several 
times in the day, and the weak muscles of the calf should be 
stimulated by massage. 

Cure may be hastened by the use of some simple form of 
retention splint to hold the foot in plantar flexion until the pos- 
terior group of muscles has recovered its power. Tenotomy or 
other operative treatment is rarely required. 

In rare instances the tibia may be bent slightly backward, 
thus increasing the deformity. In such cases the distortion of 
the bone may be overcome by manipulation and by apparatus. 

Congenital Talipes Valgus. Congenital valgus (Fig. 440) 
Lb somewhat more common than the preceding varieties (123 in 



DEFORMITIES OF THE FOOT. 



789 



1660). Xot infrequently it is combined with a slight degree of 
calcaneus or equinus. The resistance of the contracted tissues 
is not great, and the deformity may be overcome, in most cases, 
by persistent manipulation. If the muscular power is sufficiently 
unbalanced to warrant it the foot should be fixed in the over- 
corrected position (varus) for a time. 

Congenital valgus is one form of what is known as weak 
ankle, and it frequently passes unnoticed until the child begins 
to walk. If at that time, in spite of massage, the muscles appear 
weak or if the foot inclines outward when weight is borne, it is 



Fig. 485. 




Congenital calcaneovalgus. 



well to make the sole of the shoe wedge-shaped, the thicker part 
(one-quarter of an inch) on the inner side. In more persistenl 
cases a brace may be necessary, as described in the treatment <»'' 
the acquired variety. (See Weak Foot.) 

Talipes equinovalgus i- less common (28 in 1660). This 
must be treated as the other varieties, by complete overcorrection 
of deformity, manual or otherwise, and by subsequent massagi 
and support if necessary. 

Calcaneovalgus (15 in 1 660 ), calcaneovarus (7 in 1 
equinocavus (1 in 1 660), valgocavus (1 in 1660), cavus 
L660), are extremely ran-, as indicated by the statistics, [f 



r 90 



ORTHOPEDIC SURGERY. 



treated early by persistent massage supplemented by retention 
apparatus, these, as well as nearly all slighter grades of congen- 
ital deformity, may be corrected and cured even, before the child 
begins to walk. 

Congenital Deformities of the Foot Associated with 
Defective Development. 

Talipes Equinovalgus Associated with Congenital Absence of the 
Fibula. This is a rare deformity, but the most common of this 
class. The foot at birth is usually in an attitude of well-marked 



Fig. 486. 




Congenital equinovarus, with deformity of the great toes. 



and resistant equinovalgus. The leg is somewhat shorter than 
ite fellow, and the tibia is often bent sharply forward, some- 
tin tea to an acute angle, at a point somewhat below the centre, as 
if it had been broken in "tir<>. At the most prominent point the 
-kin may be adherent or it may present a dimpled appearance. 
In -Dim- instances the formation of the foot is perfect, but more 
often one or more of the outer toes, with the corresponding 
metatarsal bones, are absent (Fig. 487). 



DEFORMITIES OF THE FOOT. 



791 



Haudek collected from the literature U7 cases. Of 
in males, 21 were in females, and in 30 the sex 
67 (69 per cent.) there was total absence 



Fig. 487. 



Statistics, 
these 46 were 
was not recorded. In 
of the fibula. In 30 the 
defect was partial ; of the 
lower extremity of the fibula 
in 17, of the upper extremity 
in 9, and of the middle in 
2 cases. In 27 cases both 
fibulae were absent or defec- 
tive ; in 68 one only — the 
right in 31, the left in 25, 
and in the others the side 
was not recorded. In 61 
cases toes were lacking, and 
in these cases it may be in- 
ferred that the correspond- 
ing metatarsal bones were 
absent also. The fourth and 
fifth toes were absent in 27 
cases ; the little toe alone was 
missing in 15. In many in- 
stances, as is usual in cases 
of defective development, de- 
formity of other parts was 
present ; for example, in 1 7 
instances the patella was ab- 
sent or undeveloped, and in 
1 1 the upper extremities were 
defective. 1 

Etiology. The cause of 
deformity, associated with 
absence of bone, may be 
either an original defect in 
the germ or it may be due 

to interference with it- development. In some instances am- 
niotic adhesions may be one of the predisposing causes ; tin* 
sharp bend in the tibia, so often present, may be due to the 
lessened resistance of the defective part. 

1 Gotten and Chute. Baton Medical and Soiglca] Joarni 
Mazzitelli. Arch. OrtopedJ Inet, Rente d'Ort; Vid< 

alsoErai! Hain (USCBflee), Arcbiv Orthop. Mecbanicotherapie und fnfal Chlf. Bd. I, H. 1, IMS. 




Defective formation of the lower Limb, illus- 
trating progress In shortening. 



792 ORTHOPEDIC SURGERY. 

Treatment. The indications for treatment are to correct the 
deformity of the foot in the usual manner. The bend in the 
tibia may be straightened by manipulation and splinting, or by 
osteotomy if necessary. When the patient begins to walk the 
foot must be supported. A light steel upright on the outer side 
of the leg, provided with a T-strap to hold the leg against it, will 
supply the place of the missing fibula. The growth of the tibia 
is retarded and a final shortening of three or more inches may 
l>e expected, but with care a useful limb may be assured. 

Talipes Varus or Equinovarus Associated with Congenital Absence 
of the Tibia. Defective formation of the tibia is much less 
common than that of the fibula. Joachimsthal 1 records 31 cases. 
Of the 25 cases in which the sex was recorded 17 were males 
and 8 females. In 23 instances the defect was of one side ; in 
8 both tibiae were defective. In most cases the femur is some- 
what shortened and its lower extremity is imperfectly developed. 
In a third of the cases the patella was absent, and in many 
instances other malformations were present. In nearly all the 
cases there was flexion contraction at the knee and the fibula was 
dislocated backward. The foot is practically always in an attitude 
of varus. The toes may be normal, but in a number of instances 
the great toe was lacking. In possibly a third of the cases a 
portion of the tibia, usually the upper extremity, was present. 2 

The prognosis as regards a useful limb is extremely bad. The 
growth of both the thigh and the leg is much retarded, and it is 
almost impossible to balance the foot upon the fibula by any form 
of brace. 

The ordinary treatment, after the correction of the deformity 
of the foot, has been to resect the extremities of the femur 
and the fibula to induce anchylosis. No final results have been 
reported, but it may be assumed that an artificial limb would 
provide a more useful support than the short and distorted 
extremity. 

Congenital Deficiency and Hypertrophy. The leg bones may be 
perfectly formed, but one or more bones of the foot itself may 
be absent. Iu these cases, after the reduction of the deformity, 
a Bupport to hold the defective foot in its proper relation to the 
Leg most l><- used. 

The f<»ot may be divided into two parts, so that it resembles a 
Lobster flaw. Supernumerary toes, or deficiency of toes, or hyper- 

/• Lti C Orth. (liir., vol. iii. ]>. 140. 

noil and Kuae report 40 cases. Revue d'Orthopedie, November, 1901. 



DEFORMITIES OF THE FOOT. 793 

trophy of one or more of the toes, with or without corresponding 

overgrowth of the foot or leg, are not extremely uncommon. 

These deformities must be treated on ordinary surgical 
principles. 

Constricting Bands. 

Tightly constricting bands of scar-like tissue, which cause 
deep indentations in the flesh of the foot or leg, are sometimes 
seen. These are supposed to be caused by amniotic adhesions. 
'• Spontaneous amputations" of toes or of the foot itself are due 
to the same cause (Fig. 443). 

In ordinary cases the bands require no treatment, but if they 
interfere with the nutrition of the foot they may be removed. 

Congenital (Edema of the Feet. 

In rare instances, sometimes in combination with deformity, 
the tissues of the feet appear to be oedematous, although the circu- 
lation seems to be perfect. The condition is apparently due to 
obstruction of the lymphatic circulation. 

It should be treated by massage and by compression. 

Spinal Bifida and Talipes. 

Talipes coexisting with spina bifida should be treated as are 
other forms of club-foot. If paralysis of the lower extremities 
be present, as is often the case, the corrected feet must be sup- 
ported as in the ordinary forms of paralytic deformity. 1 

1 Ueber missbildungen der Menschilichen Gliedmassen und ihre entstehungsweise, 
Klausner. 1900. 



CHAPTER XXIII. 

DEFORMITIES OF THE FOOT (Continued). 

Acquired Talipes. 

I n the account of the congenital deformities of the foot it was 
stated that the form known as equino varus was by far the most 
common, and that as compared with it the other deformities were 
of slight importance. 

In the acquired varieties of talipes the equino varus deformity 
is much less common, the proportion in the congenital form being 
77 per cent, and in the acquired 32.5 per cent, of the total 
number. Acquired equinus comes next in frequency, 26 per 
cent, as compared with 2.4 per cent, of the congenital deformity ; 
and every variety and combination of distortion finds its repre- 
sentative in acquired talipes, as may be seen in the tables. (See 
page 742.) 

Etiology. The cause of acquired talipes is almost always 
paralysis. In the table of statistics it will be seen that in 82.8 
per cent, the paralysis was of spinal origin (anterior poliomyelitis). 
In 11.3 per cent, it was cerebral, the talipes being a part of the 
deformity of hemiplegia or paraplegia. In a few cases the de- 
formity was caused by local disease or by local paralysis, and 
the remainder, or 5.4 per cent., were of traumatic origin. 

The distinction between the two varieties of talipes, congenital 
and acquired, has already been emphasized. In the congenital 
form the deformity is the essential disability, for when deformity 
has been rectified the most difficult part of the treatment has 
been accomplished and perfect cure may be expected. In the 
acquired form the straightening of the foot is but a preliminary 
part of the treatment, for cure is not to be expected except in 
that small proportion of cases in which the primary disease of 
the spinal cord has caused no permanent injury to its structure, 
or in which the deformity was the result of some slight or pass- 
in- disability or of disease or injury. Congenital talipes cannot 
be anticipated or prevented. Acquired talipes is an effect of par- 
alysis only when protective treatment has been neglected. It is a 



DEFORMITIES OF THE FOOT. 795 

result, therefore, that may be foreseen, and thus, by proper treat- 
ment, prevented. 

Development of Deformity. The characteristics of anterior 
poliomyelitis are described elsewhere. (Chapter XVII.) In its 
effect upon the foot the usual sequence is somewhat as follows : 
At the onset the paralysis is usually widespread, affecting an 
entire limb, for example ; then follows a period of partial recovery, 
after which the amount of damage that the spinal cord has 
sustained may be estimated. It is during the period of partial 
recovery, the six months or more following the attack, that 
deformity develops. If, for example, the anterior group of leg 
muscles is paralyzed, the foot habitually hangs downward, an 
attitude induced by the force of gravity and by the contraction of 
the unaffected posterior group. If it is allowed to persist the 
tissues accommodate themselves to the new position ; the active 
muscles which are never extended to their normal limit become 
structurally shortened, while the weakened or paralyzed muscles 
are correspondingly overstretched. Even within a few weeks 
after the onset of the paralysis the evidences of progressive de- 
formity are plain. The contracted tissues resist passive motion 
in the directions opposed to the habitual attitude, and the child 
shows evidence of pain if force is used to increase the limited 
range of motion. As has been stated already, acquired talipes 
is an unnecessary deformity. It may be prevented by support- 
ing the paralyzed part in a right-angled relation to the limb, 
and by systematic passive movements throughout the entire range 
of normal motions. 

Anterior poliomyelitis is most common during the second year 
of life, or when the child has already begun to walk. When the 
first or more general effect of the disease has passed away the 
child again uses the disabled limb as best it may; thus the dis- 
tortion of the foot is increased and confirmed by the weight of 
the body and by functional use in the abnormal attitude 

The final deformity, in a particular case, can be predicted from 
a knowledge of the function of the muscles which have been dis- 
abled. For example, paralysis of the tibialis antious, the most 
powerful dorsiflexor and adductor of the anterior group, must 
result in equinovalgus. If the peroneua brevis and tertiue are 
affected varus will follow. Paralysis of the calf muscles will 
cause calcaneus. Paresis or paralysis of tie- entire anterior group 
will cause equinus. If all the muscles an- paralyzed, what i- 
called a dangle-foot is the result; the cold, atrophied member 



!)i; ORTHOPEDIC SUBGER Y. 



dangles from the attenuated limb, with but little tendency to 
deformity unless it is capable of use, when it is usually forced 
into an attitude of equinovarus or valgus. 

A slight degree of paralysis may cause so little immediate 
disability that it may be entirely overlooked, and yet it may be 
sufficient to induce disability or deformity even, in later years. 
This fact has been mentioned in the etiology of the contracted foot. 

Differential Diagnosis between Congenital and Acquired 
Deformity. The history itself usually indicates the etiology, for 
deformity of the foot at birth is never overlooked by the mother. 
Acquired talipes is of slow development, and it is practically 
always preceded by disease, weakness, or injury. 

In paralytic talipes (anterior poliomyelitis) there is evidence of 
paralysis in loss of function of certain muscles, as shown by 
electrical stimulation or by pricking the foot with a pin ; later, 
in the atrophy of the muscles and often in the evident change in 
the nutrition and diminished growth of the limb. 

Only in neglected and extreme cases of talipes in the adolescent 
or adult could there be difficulty in distinguishing between the 
acquired and the congenital deformity. In rare instances, it is 
true, paralysis may be present at birth, due to intra-uterine dis- 
ease or to defect in the nervous apparatus. In such cases the 
cause of the paralysis is usually apparent (spina bifida, or spastic 
paralysis associated with defective cerebral development), and 
the treatment does not differ from that of the acquired form. 

Acquired Talipes Equinus 

In well-marked equinus the foot is plantar flexed to its full 
limit, and it is fixed in this attitude by the shortened structures 
on the posterior aspect of the leg, of which the tendo Achillis is 
tin- most important. The patient walks upon the heads of the 
metatarsal bones, the toes being dorsiflexed to accommodate the 
deformity. The arch of the foot is increased in depth and the 
tissues of the sole, particularly the plantar fascia, are contracted. 
The entire foot is broadened and shortened, the breadth being 
especially increased at the anterior metatarsal region (Fig. 438). 
Corresponding to the exaggerated depth of the arch, the dorsum 
projects, the eimeiform bones are prominent, and the head and 
body of the displaced astragalus may be felt beneath the skin on 
the anterior surface of the foot. In the slighter degrees of the 
deformity, when the patient still walks upon the sole of the foot, 



DEFORMITIES OF THE FOOT. 



797 



the toes are usually dorsiflexed — an attitude due apparently to the 
overaetion of the extensor longus digitorum and proprius hallucis, 
as aids in dorsiflexion (Fig. 488), 

In rare instances, and only in those cases in which all the 
anterior muscles are paralyzed, the toes may be plantar flexed 
so that the patient walks upon their dorsal surface. 

The cavus or increased depth of the arch is due primarily to 
the falling downward of the forefoot at the mediotarsal joint, and 
in many instances this dropping of the forefoot is in great degree 
responsible for the equinus ; in fact, the os calcis is rarely plantar 
flexed to the degree commonly found in the ordinary congenital 
equinus. 

Fig. 488. 




Acquired talipes equinus, showing the limit of dorsal flexion. 



The cases of slight equinus combined with cavus have been 
described already under the title of the contracted foot (page <'»•'•» ). 
The exaggerated arch is a secondary and a late result of tin- 
paralysis and of the equinus. In the slight degrees of deformity, 
particularly in the early stage of the paralysis, it may !»<■ absent. 

Etiology. Equinus in the slighter degrees is the most common 
of the forms of talipes acquired in later life Anterior poliomy- 
elitis, although by far the most common cause, is by no means 
as important in the etiology of this as of other varieties of defor- 
mity. The nerve supply of tin- anterior muscles "f the fool 
seems to be particularly susceptible, and toe-drop, from neuritis 
of various type-, i- not uncommon* 



798 OR THOPEDIC S URGER Y. 

Equinue may he a result of disease of cerebral origin, or even, 
in rare instances, of pseudohypertrophic muscular paralysis or 
locomotor ataxia. It is sometimes induced by habitual posture, 
as after long confinement in bed for the treatment of fracture 
or during the treatment of hip disease by apparatus. Or the con- 
traction may be an effect of voluntary posture, as when the 
patient habitually walks upon the toes because of a short leg. It 
is a very common sequel of neglected disease at the ankle-joint, 
and it may be a result of direct injury. 

The changes in the internal structure of the foot are similar to 
those that follow other forms of deformity ; the tissues on the 
long side are lengthened and attenuated, while those on the short 
side become coutracted. The bones themselves are but little 
changed in gross appearance, but the articulating surfaces are in 
abnormal relation to one another ; for example, only the posterior 
part of the astragalus may be contained within the malleoli in 
relation to the tibia, while only the lower part of its anterior sur- 
face articulates with the navicular. In all cases of equinus there 
is a strong tendency toward varus or valgus. This is especially 
noticeable in those of paralytic origin. 

Symptoms. The effects of the deformity vary. If the limb 
is actually shorter than its fellow, so that the lengthening caused 
by the extension of the foot is no more than a sufficient compen- 
sation, and if the foot is firmly fixed in the deformed position, 
surprisingly little discomfort or disability may be experienced 
other than from corns or calluses beneath the metatarsal bones. 

If the limb is not shorter the additional length caused by the 
equinus must be compensated by a tilting of the pelvis and lateral 
deviation of the spine. This often gives rise to symptoms of 
discomfort in the lumbar region. The gait in this class of cases 
i- always awkward, giving the impression as of stepping over an 
obstacle. 

If the foot is not fixed in the attitude of equinus — that is, if it 
hangs downward when it is lifted — the gait is very awkward, 
because of the insecurity and because of the exaggerated flexion 
at the knee necessary in order that the pendent foot may not drag 
upon the ground. 

If the equinus is extreme the limb is usually flexed at the 
knee when in use; if the equinus is slight, so that the foot may 
be used in the plantigrade position, the strain resulting from the 
limitation <>f dorsal flexion is felt at the knee ; and in childhood 
at least there is often a well-marked tendency to overextension 



DEFORMITIES OF THE FOOT. 799 

or recurvation, caused by the effort to place the heel upon the 
ground. 

In the slight degrees of equinus discomfort about the calf is 
experienced ; the limitation of dorsal flexion causes a rather 
shortened stride and awkward gait, while an unguarded step that 
throws a sudden strain upon the rigid heel cord is felt as a shock 
and strain through the leg and bod}-. Very often the patient 
complains of pain about the metatarsal bones (anterior metatar- 
salgia), and if the equinus is accompanied by a slight degree of 
valgus, as is not uncommon, symptoms of the weak foot may be 
present. 

The prognosis as to permanent cure depends, of course, upon 
the cause of the deformity. When it is simply the result of 
posture or of the ordinary form of neuritis and the like, perma- 
nent cure may be expected. In many of the cases that have 
followed anterior poliomyelitis recovery, complete or partial, of 
the original injury to the spinal centres, has occurred. Although 
voluntary control of the muscles has been regained, it cannot be 
exercised because the foot is held in the distorted position by the 
contracted tissues. In such instances practical cure may be pre- 
dicted if, after the overcorrection of deformity, sufficient time is 
allowed for the overstretched and atrophied muscles to regain 
their proper length and volume. 

Treatment. In the cases of fixed equinus combined with a 
shortened limb in which the patient suffers no discomfort it is 
well to allow the position to remain, a shoe being so built that 
the heel may support a part of the weight. In the more extreme 
cases in which the limb is short and the foot is atrophied an 
extension shoe, attached after the manner of an artificial leg, may 
be worn with comfort and with but little evidence of deformity. 

In the ordinary cases, whether permanent cure is expected or 
not, the rule holds good that the heel should bear the weight of 
the body, and that the range of dorsal flexion should not be 
limited when the calf muscle retains its power. If the nervous 
apparatus has received permanent injury the foot must be sup- 
ported after the deformity has been corrected ; but even in this 
class the gait may be improved and the discomfort may be 
relieved by removing the restrictions to normal mo! ion. 

The slight degrees of equinus in young subjects may be over- 
come by simple manipulation or by retention in a splint or in a 
plaster bandage. If the foot is fixed by a plaster bandage al a 
right angle to the leg it will be found after a few weeks thai the 



800 



nirruorEDic surgery. 



range of dorsal flexion has been increased by the rest and by 
functional use. In older subjects manual stretching of the con- 
tracted tissues is of service ; for example, the patient being seated 
extends the limb; the surgeon stands in front of him, one hand 
holds the Leg firmly at the ankle, and the other grasps the foot, 
which is then dorsi Hexed over and over again with as much 
force as is consistent with the comfort of the patient. 

The Shaffer extension shoe is also a useful appliance for treat- 
ment of the milder degrees of equinus, and especially so because 



Fig. 489. 



Fig. 490. 





A brace with a " limited " joint, allowing 
slight motion at the ankle. 



A brace to prevent foot-drop. One upright 
is often sufficient. 



it may be employed to reduce the accompanying cavus at the 
same time. 

The weight of the body as a means of overcoming equinus 
when the foot is held in its proper relation to the leg by a brace 
or by a plaster bandage has been mentioned, but this tedious 
method has but little to recommend it in the cases of more 
resistant type. The clastic tension of straps and bands attached 
to a brace or to the foot itself by means of adhesive plaster is 
of some service in slight cases; but by far the most effective 



DEFORMITIES OF THE FOOT. SOI 

method is the immediate reduction of the deformity by simple 
forcible manipulation under anaesthesia, or by tenotomy combined 
with forcible manipulation or wrenching. 

Immediate Correction of Deformity. Attention has been called 
to the cavus as an important element in equinus, and whenever 
one attempts to correct the equinus deformity by force the exag- 
gerated arch should be reduced to its normal depth, otherwise 
the foot will appear stunted and deformed. 

One of the most effective procedures is forcible reduction by 
means of the Thomas wrench (Fig. 472). The resistant bands 
of the plantar fascia are first divided subcutaneously, the wrench 
is then fixed to the foot, and with sudden force exerted against 
the resistant tendo Achillis the foot may be straightened, the 
deep ligaments being ruptured or stretched to the proper degree. 
The resistance to normal dorsal flexion is then overcome by 
manual force, or, if this is ineffective, by subcutaneous division 
of the tendo Achillis, and the foot is fixed by a plaster-of-Paris 
bandage in an attitude of dorsiflexion. 

As the patient is encouraged to walk upon the foot as soon as 
possible, the weight of the body forcing the relaxed tissues against 
the plaster sole, reinforced, if necessary, by a wooden foot plate, 
completes the flattening of the arch. In many of these cases the 
knee has been overextended by use in the deformed attitude, so 
that the habitual flexion necessary to bring the dorsiflexed foot 
upon the ground during the two months allowed for the complete 
union of the divided tendon is of benefit, as it serves to correct 
this secondary weakness and deformity. 

The Tonic Effect of Immediate Correction, The 
importance of the tonic effect of immediate relief of the strain of 
the deformed position upon the weak anterior group of muscles, 
together with the complete relaxation of the overstretched tissues, 
during the long rest in the overcorrected position is not generally 
appreciated. Whenever the weakened muscles after paralysis 
show by tests, electrical or otherwise, that they have recovered 
their power in part, overcorrection of the deformity Bhould he 
the treatment of selection. The application <>f electricity or other 
form of -Tiiniilation to muscles thai are unable to exercise their 
function because of contraction <-f tie- opposing tissues is absolutely 
ageless; nor is any other form of artificial stimulation equal to 
that of the functional use, which i- made possible by the removal 
of the deformity and by the employment <>f proper suppo 

Bquinus, more often than any other deformity, ie the result of 



802 



ORTHOPEDIC SURGERY. 



slight or temporary disability of the anterior group of muscles, 
and not infrequently perfect cure seems to have been attained 
when the plaster baudage is finally removed, usually at the end of 
two months or more ; but even in such cases the application of 
a simple support to hold the foot at a right angle with the leg for 
several months is of advantage. The after-treatment by massage, 
muscle-beating, electricity, and the like, combined with method- 
ical passive movements to the limit of dorsal flexion to guard 



Fig. 491. 





An effective and inconspicuous support for paralytic toe-drop. An uprignt of light tem- 
pered steel, carefully adjusted to the inner side of the leg and ankle, provided with a light 
calf band. This is strengthened by a posterior support attached to the upright. The lower 
end of the brace is arranged as a caliper and is fitted to the metal disk, of which two views 
are shown. A depression is cut in the heel of the shoe for the disk, as is shown in the dia- 
gram. Two strong elastic tapes are sewed to the leather of the shoe. These are attached 
to the studs on the front of the calf band, and thus the toe-drop is prevented. (See Fig. 492.) 

against recontraction of the calf muscle, should be continued for 
a Long time or until the muscular balance has been regained. 

Support is, of course, necessary, in cases of hopeless paralysis, 
to hold the foot at a right angle with the leg. The common 
form La a simple steel sole plate of sufficient size to support the 
sole, and the toes, also, if their muscles are paralyzed, attached to 
a light upright, provided with a calf band. The upright is 
usually applied on the inner side of the leg, where it is least 



DEFORMITIES OF THE FOOT. 



803 



Fig. 492. 



noticeable. At the ankle there is a " stop joint/' which allows 
dorsiflexion but prevents the toe-drop. This, when properly 
fitted, can be placed inside the ordinary shoe, as the paralyzed 
foot is usually somewhat smaller than its fellow (Fig. 490). If 
the toes do not need support, 
the upright can be attached 
to the outside of the shoe and 
the foot plate may be dis- 
pensed with ; or, the upright 
may be concealed by intro- 
ducing it inside the shoe to 
a joint sunk in the heel, the 
toe-drop beiug prevented by 
straps passing from the front 
of the upper leather of the 
shoe to the calf band (Fig. 
491). 

Arthrodesis. In this class 
of cases in which the ante- 
rior muscles are paralyzed 
the operation of arthrodesis 
for the purpose of fixing the 
foot at a right angle with 
the leg is of value. In most 
cases anchylosis must be se- 
cured at the mediotarsal as 
well as at the ankle-joint. 

j~r j ,i -p, i , , The same appliance (Fig. 491) provided with a 

L nder the ±,smarch bandage f00t plate of meta i or of wood, as shown in the 
the two joints are opened by dia e ram - Th , is modification i B useful if the par- 

• L J alysis is complete or if the foot is much atrophied. 

an incision in the centre of 

the foot, beginning about one inch above the ankle-joint and ex- 
tending downward for about three inches. The cartilaginous sur- 
faces of the astragalus and leg bones may be removed easily with 
a narrow-bladed knife or thin, sharp chisel, while the foot is 
held in plantar flexion. At the mediotarsal joint a thin, wedge- 
shaped section, base upward, including the astragalonavicular 
and calcaneocuboid joints, may be removed also in order to pre- 
sent the subsequent sinking of the forefoot. 

If there is restriction of dorsal flexion the fool should be forced 
up to a right angle with the l'-_ r against the resistance of the tendo 
Achillis, thus determining tie- apposition of the denuded surfaces. 
In other instances silk sutures may be passed through the perios- 




804 ORTHOPEDIC SURGERY. 

team of the opposing hones. The wound is then closed with 
catgut and a plaster-of-Paris bandage is applied to hold the foot 
at a right angle with the leg. Operations of this character on 
the bones an* sometimes followed by swelling. On this account 
the bandage should be applied tightly over a thick layer of elastic 
cotton and the foot should be elevated. As soon as the discom- 
fort has subsided the patient should use the foot in walking. 
No support is equal in efficiency to the plaster bandage, and this 
should be worn for several months, when it may be replaced by 
a light supporting brace of the Judson type (Fig. 494). 

Equinus due to posture or to disease, not involving paralysis, 
may be cured by simple correction of the deformity. That due 
to fracture, when the deformity is caused by displacement of the 
bones, may be treated by direct operation or by the removal of a 
cuneiform section from the anterior surface of the tibia above the 
ankle. (See Tendon Transplantation.) 

Acquired Talipes Calcaneus. 

Acquired talipes calcaneus is much less common than equinus, 
and it is practically always of paralytic origin (anterior polio- 
myelitis), although cases of calcaneus following injury or disease 
or distortion of the limb are occasionally seen. 

There are several varieties or grades of the deformity. In the 
early stage, and especially if all the muscles of the posterior group 
have been paralyzed, the foot assumes an attitude of slight dorsi- 
flexion, and the range of plantar flexion is gradually lessened by 
secondary contractions. This variety resembles closely the con- 
genital form (simple calcaneus) (Fig. 439). In the ordinary and 
typical form of calcaneus, when fully developed, the patient 
walks, as the name implies, on an elongated heel. The arch of 
the foot is much increased in depth, and the forefoot is atrophied 
and useless (calcaneocavus) (Fig. 495). 

Development of Deformity. The development of the deformity 
i- somewhat a- follows : When the tension of the calf muscle is 
removed the «.~ calcis gradually assumes an attitude of extreme 
dorsiflexion. It stands on end, so that its posterior surface 
becomes inferior. The posterior projection of the heel is lost, 
and it lie- in the plane of the atrophied calf. The change in the 
position <>f the os calcis increases the distance from the malleoli 
to the ground ; thus calcaneus, though in less degree than equinus, 
makes the limb Longer. The turning of the heel on end increases 



DEFORMITIES OF THE FOOT 805 

the depth of the longitudinal arch and at the same time shortens 
the foot, thus cavus, in more marked degree than with equinus, 
accompanies calcaneus. The cavus is a later complication of nearly 
all cases of paralytic calcaneus. In many instances there is no 
permanent dorsiflexion or elevation of the forefoot, although in 
all cases the range of plantar flexion is limited. In this class the 
power in the remaining muscles of the posterior group is probably 
sufficient to counterbalance the action of the dorsiflexors. Cavus 
is thus a direct effect of the displacement of the os calcis. If 
the entire posterior group of muscles is paralyzed, while the 
anterior muscles are unaffected, the foot will be somewhat dorsi- 
flexed and the cavus will be less marked. If the calf muscle only 
(gastrocnemius and soleus) is paralyzed, the remaining muscles 
of the posterior group will counterbalance the dorsiflexors and at 
the same time increase the cavus. In some instances the calf 
muscle alone is affected ; in others one or more of the smaller 
muscles may be paralyzed also, in which case the foot is usually 
turned toward varus or valgus. The changes primarily caused 
by the paralysis and by unopposed muscular action become fixed 
by habitual use and by secondary adaptation of the tissues. The 
heel only is used in walking, and the area of callus which marks 
the weight-bearing surface becomes much enlarged, while the 
forefoot and toes, which have but little functional use, become 
atrophied — a mere appendage to the enlarged heel (Fig. 496). 

Symptoms. The gait is awkward and inelastic ; the patient, 
who is, as it were, " hamstrung," stamps along upon the insecure 
support of the heel in a manner which is easily recognizable by 
one familiar with the deformity. The changes in the internal 
structure of the foot, the inevitable adaptations to the deformity, 
do not call for special description. The disused bones atrophy 
together with the other tissues, and new articulating surfa 
form to accommodate the necessities of functional use. 

Treatment. The essence of successful treatment i- prevention. 
When the diagnosis of paralysis of the calf muscle is made one 
may predict, unless recovery takes place, a deformity such as lias 
been described. This deformity may 1»<- prevented by proper 
support, by ma-sage, and methodical stretching of the tissues thai 
have a tendency to contract The form of brace used for walking 
and support should be provided with a sole plate, upright, and 
calf band, as already described in the treatment of paralytic 
equinus. If motion i- allowed al the ankle it should he in plantar 
flexion only, the -top being the reverse of that used in equinus • 



SOU 



mrriroPEDic surgery. 



or, as this form of check entails much strain upon the brace, the 
joint may be omitted, as in that form used by Judson (Figs. 493 
and 494). Thus the strain, removed from the weakened tissues, 
is borne by the anterior surface of the leg. Other forms of 
I) races are sometimes employed, provided with elastic bands to 
supply the place of the calf muscle ; but, as a rule, the improve- 
ment in gait hardly compensates for the trouble in adjustment or 
the conspicuousness of the appliance. 

The most important part of the actual deformity of calcaneus 
is the cavus, in great degree due to the changed position of the 
os calcis ; and in confirmed cases it is practically impossible to 



Fig. 493. 



Fig. 494. 





Judson's brace for calcaiieous deformity. 



reduce this except in part, because the loss of resistance of the 
ten do Achillis, takes away the point of fixation against which 
effective force can be exerted. If the deformity is not marked 
the foot may be drawn as far as possible toward equinus and fixed 
in a plaster bandage, the sole part being strengthened by the inser- 
tion of a thin board. Upon this the patient may walk, the heel 
being built up with cork wedges to make the sole level. When 
the contraction of the anterior tissues has been overcome the 
brace is applied and the usual treatment of manipulation and 
massage is continued. 

The method of prolonged fixation in the attitude of equinus by 
means of the plaster bandage is often efficacious in childhood, 



DEFORMITIES OF THE FOOT. 



807 



when the paralysis is Dot complete, and cures of apparently hope- 
less cases by this means have been reported. 1 

Operative Treatment. In more extreme cases immediate reduc- 
tion of the deformity under anaesthesia may be attempted. The 
contracted tissues, more particularly the plantar fascia, may be 
divided subcutaneously or by open incision ; then by forcible 
manipulation or wrenching the sole may be somewhat lengthened 
and the heel pushed upward and backward to permit of slight 
plantar flexion. In this attitude the foot should be fixed by 

Fig. 495. 




Paralytic calcaneus, showing secondary changes in contour. 

means of a plaster bandage. In the reduction of the deformity 
one must not merely force the fort-foot downward, as this would 
simply increase the cavus, but whatever correction is accomplished 
should be by means of elevation of the os calcis and elongation 
of the tissues of the sole of the foot. In cases of extreme de- 
formity the contracted tissues in the anterior aspect of the ankle 
must be divided also. 

In some instance- the improved position of the os calcis may 



Gibney. Transactions of the American Orthopedic Association, 1'jOO, vol. xiii. 



SOS 



ORTHOPEDIC SURGERY. 



be confirmed by shortening the tendo Achillis, as first performed 
by Willett, of London. 1 

Willett's Operation for Calcaneus. A Y-shaped incision about 
two inches in length is made through the tissues down to the 
tendon. At the lower or vertical part of the incision, which is 
continued down to the tuberosity of the os calcis, the tendon is 
dissected free from the surrounding parts. It is then divided in 
an oblique direction from within outward and downward, and the 



Fig. 496. 




Talipes calcaneus due to paralysis of the calf muscle (gastrocnemius and soleus), 
illustrating the typical deformity of moderate degree. 

heel having been pushed upward as far as possible the divided ends 
are overlapped and sutured ; the flap of skin is drawn downward 
at the same time, so that the Y-incision is converted into the 
shape of a Y. According to Mr. Willett's original directions, 
deep sutures are passed through the skin flaps and through the 
tendon on either side, so that all the tissues are united. The 
foot i> then fixed in a plaster bandage in an attitude of equinus. 
A.8 Boon afi practicable the patient begins to use the foot, wearing 
a high heel to compensate for the elevation of the sole. 



1 St. Bartholomew's Hospital Reports, 1880, vol. xvi. p. 309. 



DEFORMITIES OF THE FOOT. 



809 



The operation is of value in those cases in which some power 
remains in the calf muscle, which is thus made serviceable. 



Fig. 497. 




Talipes calcaneovalgus. In this form the adductors of the foot (tibialis anticus and 
posticus) as well as the calf muscle are paralyzed. 

In cases of complete paralysis the position of the foot may be 
temporarily improved, but unless proper support is used afterward 



Fig. 498. 



Fig. 499. 





Compare with Pig 



Tom part- with 



the tissues" will stretch under the strain of use; thus the treat- 
ment should always be supplemented by a brace of the character 
already described (Fig. 494). 



810 ORTHOPEDIC SURGER Y. 

Astragalectomy, Tendon Transplantation, and Backward Displace- 
ment of the Foot (the Author's Operation). 1 In cases of confirmed 
calcaneus or calcaneus combined with lateral deformity, varus or 
valgus, astragalectomy may be indicated. This operation permits 
the malleoli to be brought into direct contact with the os calcis, 
thus increasing the security of the foot and improving its appear- 
ance. 

A long, curved, external incision is made, passing from just 
anterior to the tendo Achillis below the outer malleolus to the 
front of the joint. The peronei tendons are divided or drawn to 
one side. The joint is then opened and the foot is displaced in- 
ward. 

This forces the astragalus out from between the malleoli and 
it is easily removed when its attachments to the neighboring 

Fig. 500. 



Figs. 498, 499, and 500 illustrate the effect of treatment by removal of the astragalus and 
backward displacement of the foot in cases of paralytic talipes calcaneovalgus. 

bones have been divided. The articulating surfaces of the leg 
I x uics and of the os calcis and navicular are denuded of car- 
tilage ; and, finally, the peronei tendons, if the muscles are active, 
are attached to the os calcis, preferably by passing them through 
a hole bored just beneath the insertion of the tendo Achillis, for 
the purpose of lessening the tendency to deformity and increas- 
ing the subsequent stability of the foot. The entire foot is then 
displaced backward so that the denuded malleoli overlap the 

1 American Journal of the Medical Sciences, November, 1901. 



DEFORMITIES OF THE FOOT. $n 

anterior extremity of the os calcis. The object of this procedure 
is to throw the weight of the body toward the centre of the 
tarsus in order to lessen the leverage that tends to force the 
foot toward dorsal flexion. The wound is then closed without 
drainage, and the foot is fixed in plaster of Paris in moderate 
equinus. 

As soon as possible the patient uses the foot in standing and 
walking. Ultimately apparatus may be dispensed with, but the 
Judson brace or the appliance shown in Fig. 501 may be used 
for a year or more with advantage. This operation has been 
performed in many instances by the author, for whom it is now 



Fig. 501. 




An effective brace for talipes calcaneus, consisting of two light lateral steel bars joined 
above by a padded band of steel, which crosses the upper third of the tibia, and below by a 
narrow sole plate. A leather heel support also adds somewhat to the efficiency of the appa- 
ratus. In most instances the heel should be somewhat elevated by a cork wedge placed 
within the shoe. 

the treatment of choice in this type of deformity. It may In- 
stated that absolute anchylosis does not follow the denudation of 
the bones, but this seems to be of service in lessening the 
direct strain upon the articulation. The tendon transplantation 
is rather for the purpose of removing an agent toward deformity 
if valgus is present and to lessen the tendency toward deformity 
than to replace th<- Lost function of the calf muscle (Fig. 199). 
By this operation the usefulness of tli<; foot is greatly incr< 
and its appearance very much improved. 



S 1 2 OR TH OPE DIC S URGER Y. 

Acquired Calcaneovalgus and Calcaneovarus. 

In many cases, the foot deformed as a result of paralysis of 
the calf muscle is in addition turned in a lateral direction, so 
that the weight of the body falls to the inner or outer side of its 
centre (Fig. 497). 

Calcaneovalgus, in which the foot is turned outward and 
upward, so that the patient walks on the inner side of the heel or 
even on the inner ankle, is not uncommon. It is usually a result 
of more extensive paralysis than simple calcaneus. For example, 
all the muscles about the foot may be disabled except the peronei, 
or in cases of a milder type the tibialis anticus may be the only 
muscle of the front of the foot that is paralyzed. 

Treatment. When the foot inclines toward calcaneovalgus it 
is difficult to hold it in proper position. The usual method is to 
apply the brace, vised for ordinary calcaneus, with the upright on 
the outer side of the foot ; the ankle and arch are then held 
against it by means of a leather strap. Another form of brace is 
provided with an upright on either side of the leg, the outer 
being slightly longer than the inner, so that the sole plate is tilted 
inward or, as it were, supinated ; thus the weight is guided 
toward and balanced on the outer side of the foot. In many 
instances of this character other muscles of the limb are paralyzed, 
the deformity of the foot being but a part of more general dis- 
tortion. In such cases the foot brace must be combined with 
apparatus for the support of the leg (Fig. 359). 

Calcaneovarus is a much less serious affection, since the foot 
may be more easily supported. A brace, such as is used in the 
treatment of ordinary varus, without motion at the ankle or pro- 
vie l<?d with a reverse stop, is ordinarily employed. Operative 
treatment is indicated for confirmed deformity of the valgus or 
varus type after the method last described. 



Acquired Talipes Equinovarus. 

Talipes equinovarus is, in the acquired as in the congenital 
form, the most common of the deformities of the foot (Fig. 
505). 

The tendency of simple equinus is usually toward varus, because 
in plantar flexion the foot is slightly adducted and because the 
outer side of the foot is shorter than the inner side, so that in 



DEFORMITIES OF THE FOOT. 813 

walking with the foot extended the tendency of the foot is to 
turn somewhat inward. Equinovarus is usually preceded by 
equinus, and the etiology of the one will serve for the other 
(page 796). 

In certain case? the varus is more marked than the equinus, 
as, for example, when the abductors of the foot are paralyzed 
while the adductors retain their power ; or in cases of direct 
injury, as in fracture at the ankle ; or when the growth of the 
tibia has been arrested, as the result of injury or disease. 

A detailed account of the appearance and effect of the deformity 
is unnecessary. In the early stage of the paralysis it may be 
reduced easily ; the foot must then be supported by a brace, of 
which the Taylor club-foot apparatus is the type (Fig. 4(>3). 
During the night the overcorrected attitude may be assured by a 
strap running from the upright to the sole plate. 

If the deformity is fixed it should be reduced and overcorrected 
by forcible manipulation under anaesthesia. Division of resistant 
parts is less often necessary than in the congenital form, but it 
may be required in neglected cases. The overcorrected position 
should be retained until time has been allowed for the recontrac- 
tion of the lengthened tissues ; for, as has been mentioned in the 
treatment of equinus, overcorrection and rest is by far the most 
effective treatment that can be applied to a weak or paralyzed 
part. A support is then used of the character indicated. 

Astragalectomy and cuneiform osteotomy are rarely indicated, 
but the latter operation is sometimes of service in checking the 
tendency toward recurrence of deformity, which is more persistent 
after overcorrection in the paralytic than in the congenital talipes. 

Transplantation of half of the tendon of the tibialis anticus 
tendon to the periosteum or bone of the outer border of the foot, 
combined with arthrodesis of the astragalus scaphoid articulation 
in an attitude of slight abduction, is of service as a curative 
procedure. (See Tendon Transplantation.) 

Acquired talipes equinovalgus is much less frequent than the 
preceding deformity. Simple equinovalgus is usually the result 
of primary paralysis of the tibialis anticus, the most powerful of 
the dorsal flexors; thus the foot is drawn somewhat outward 
when dorsiflexed, while the metatarsal bone of the great toe, 
having lost the proper support of the paralyzed muscle, falls down- 
ward and is drawn outward by the peroneus Longus. In this 
type one's attention is often attracted by the peculiar appearance 
of the great toe, which is deformed somewhat like a bammer-toe 



S 1 [ ORTHOPEDIC SURGEE Y. 

by tlu> overaotion of the extensor longus hallucis in its attempt 
to take the place of the tibialis anticus. The equinus is usually 
slight and is secondary to the valgus. Treatment may be begun 
by placing the foot in a plaster bandage in an attitude of varus 
and allowing the patient to walk upon it until the tendency 
toward deformity has been overcome. A support with the 
catch, as for toe-drop, is applied to the shoe, and the tendency 
toward valgus is checked by raising the inner border of the sole 
or by the use of a sole plate, as in the treatment of the simple 
weak foot (Fig. 413). In this class of cases tendon transplanta- 
tion, particularly the implantation of the tendon of the extensor 
longus hallucis in the region of the navicular. Combined with 
arthrodesis of the astragalonavicular articulation in the attitude 
of adduction is particularly effective. 

Acquired simple talipes valgus from combined paralysis of 
the tibialis anticus and posticus is rare. Talipes valgus, as when 
the foot is dislocated outward, in cases of complete paralysis of 
all its muscles, may be considered as a variety of dangle-foot. 

Traumatic valgus and equinovalgus caused by fracture at 
the ankle (Pott's fracture) may be treated by osteotomy of the 
tibia above the ankle. By this means the proper relation of the 
leg to the foot may be restored in many instances. Equinovalgus 
of slight degree is not uncommon after tuberculosis or rheumatoid 
disease at the ankle or at the astragalonavicular joints. This is 
practically one variety of weak foot. 

Talipes valgus, sometimes called spurious valgus, the simple 
weak or flat-foot, has been described elsewhere. (Chapter XX.) 

Talipes caused by cerebral disease, whether of the paraplegic 
or the hemiplegic type, is in early childhood almost always of 
the form of equiuovarus. In adolescence the deformity may be 
equinovalgus or even calcaneovalgus if there is extreme flexion at 
the knee. The hemiplegic form of talipes is much more rigid 
and unyielding than the paraplegic type. The treatment of 
spastic paralysis, of which the deformity is a part, is discussed 
elsewhere. (Chapter XVIII.) The deformity must be corrected 
by the ordinary methods. In many instances when the contrac- 
tu >n< are not marked mechanical treatment is unnecessary. 

Hysterical equinovarua or other form of deformity is not espe- 
cially ran-. The diagnosis may be made from the other symptoms 
of hysteria, from the history of the onset and duration of the 
distortion, and from the appearance of the deformity, which is 
evidently merely an assumed posture. (See page 621.) 



DEFORMITIES OF THE FOOT. 



815 



Tendon Transplantation for the Relief of Paralytic Talipes. 

When one or more of the muscles are paralyzed the unbalanced 
action of those that remain tends to distort the foot. The object 
of the brace in such cases is to hold the foot so that the muscular 
traction, however applied, can move it only in the proper direc- 
tions. The object of tendon or muscle transplantation is to utilize 
the muscular power that remains to the best advantage. Thus a 
muscle which only serves to distort the foot may be transplanted 
to a point where it may restrain deformity and improve functional 
ability. 

Tendon transplantation was first performed by Nicoladoni in 
1882 1 for the relief of paralytic calcaneus. The tendons of the 
peroneus longus and brevis were divided behind the external 
malleolus, and the proximal ends united to the distal extremity 
of the divided tendo Achillis. 

The first operation on the front of the foot was performed 
by Parish, 2 of Xew York, for the relief of paralytic valgus, by 
sewing the tendon of the extensor proprius hallucis to that of the 
paralyzed tibialis anticus, without division of either tendon. In 
more recent years the field of the operation has been extended by 
Drobnik, 3 of Posen ; Goldthwait, 4 of Boston, and many others, 
to include almost every possible combination of tendons and 
muscles. 5 

The functions of the muscles and their relative order of impor- 
tance in the execution of each movement are indicated in the 
following table, modified somewhat from that of Codivilla : 



Tibialis anticus . 
Extensor proprius hallucis. 
longus digitorum' 5 
Peroneus brevis . 
" longus 
Gastrocnemius and soleus 
Tibialis posticus 
Flexor longus hallucis 

digitorum . 



Dorsal 


Plantar 


Adduc- 


Abduc- 


Prona- 


flexion. 


flexion. 


tion. 


tion. 


tion. 


1 










3 










2 






3 


*3 




6 




2 


2 




3 




1 


1 




1 


2 






... 


4 


1 






... 


2 


3 








5 


4 


... 





tion. 



Time for Operation. Tin- opera! ion should not be undertaken 
until the rh'gree of final and irremediable paralysis baa been 



i Archiv f. klin. Chir.. 1882, iii., xxvii., S. 860. 

: New York Medical Jourm.. 

* Transactions of the American Orthopedic Association. ]*'.»'>, vol. viii. 

5 For a complete bibliography up to 1902, see Vulpitu, 
Leipzig, 1902. 

6 Including peroneus tertius. 



FM. G02. 



Fig. 503. 



mi 



filial 



GASII 



I u s 



1 



The muscles and tendons on the front of the The muscles and tendons on the hack of the 
leg. (Testut, from Gerrish's Anatomy.) leg. (Testut, from Gerrish's Anatomy.) 



D EF OR MI TIES OF THE FOOT. 



817 



Fig. 504. 



determined. This stationary stage may be reached in a com- 
paratively short time, but in the ordinary cases in which, for 
want of protection, the part has become distorted, it is practically 
impossible to estimate the latent muscular power uutil the defor- 
mity has been corrected, and until the enfeebled muscles have 
been stimulated by functional use. In general, a period of two 
years at least should intervene between 
the onset of the paralysis and the 
operation. 

The first essential for success by this 
means is a clear understanding of the 
mechanism of the disabled part and of 
the relative importance of its functions. 
As regards the foot, for example, 
plantar flexion is far more important 
than dorsal flexion, because the ina- 
bility to plantar flex implies the loss 
of the principal lifting and propelling 
power of the body. Dorsal flexion is 
more important than adduction or ab- 
duction, because the drop-foot, so 
called, interferes seriously with loco- 
motion. Adduction is more important 
than abduction, because the loss of 
power to turn the foot inward induces 
the attitude of valgus, which is more 
disabling and more difficult to remedy 
than the opposite deformity. To the 
importance of these movements the 
power of the muscles corresponds. 1 

Selection of Muscles. In selecting 
muscles for transplantation one at- 
tempts usually to reduce the distorting 
power as well as to replace lost func- 
tion. For example, if the tibialis an- 
ticus were paralyzed one would natur- 
ally replace it by its adjunct, the ad- 
joining tendon of the extensor hallucis, and as the power of rais- 
ing the toe is not essential it should be separated and transferred 
entire to its new position. This might complete the operation, 
or tho principal abductor on the dorsal surface of the fool might 




Tendoni in the right pole. (Teatnt 
from Gerrish'i Anatomy.) 



See Tables on page 



818 



n/yniorijDic sri;<;i;nY. 



be divided and the proximal end attached to the periosteum or 
bone near the centre of the foot to further assure the success of 
the operation. 

If, on the other hand, the dorsal abductors were reduced in 
Btrength so that the foot turned inward in dorsiflexion, the 
tibialis anticus tendon should be split, from its insertion to the 
muscular substance, and the outer half carried uuder the other 
tendons and fastened securely at or near the insertion of the 
peroneua tertius as well as to that tendon; thus, the power of 
supination would be weakened and that of pronation increased. 



Fig. 505. 




Paralytic equinovarus before operation. (See Fig. 506.) 

If the ealf muscle is paralyzed and if the foot is inclined 
toward valgus because of weakness of the adductor group, the 
two peronei tendon may be attached at the insertion of the tendo 
Achiilis, not, of course, with the aim of replacing its lost func- 
tion by two such feeble muscles, but because they might aid in 
preventing deformity and become of some functional service, even 
if Blight 

Paralysis of the tibialis posticus muscle may be treated by 
dividing the peroneua brevia at or near its insertion, passing it 



DEFORMITIES OF THE FOOT. 



819 



beneath the tendo Achillis and attaching it to the tendon of the 
former. It may be mentioned, also, that portions of the tendo 
Achillis have been used to strengthen either the posterior 
adductors and abductors. As has been stated, one must plan the 
operation according to the function that is lost and the power 
that remains. As a rule, the most successful operations are 
those in which a muscle of similar function to that of the 
paralyzed one is transplanted. It is apparent, also, that it will 
be of little use to transpose a muscle unless its origin is such 
that it can work to advantage at its new point of attachment. 



Fig. 506. 




Paralytic equinovarus cured by operation, showing power of dorsal flexion (one-hnlf 01 
the tendon of the tibialis anticus attached to the periosteum of the outer bonier of the fool 
Operation July 19, 1898. The direct union of tendons to periosteum at the most advantageous 
point has been urged recently by Lange (Ueber Perioatale Schnenverplanzung bei LUhgmung, 
Munch, med. Woch., 1900, No. 15). 



For example, an anterior adductor may be changed to an 
abductor, and a posterior adductor or abductor can be similarly 
transferred, but a posterior abductor is unlikely to be effici< nt ae 
a dorsal flexor; nor can one muscle act a- an extensor and a- a 
flexor at the same time, as would appear to be the belief of those 
who attach a portion of the tendo Achillis to the tibialis anticus 
tendon with the aim of restoring the power of dorsal fl< 
The variety of combinations of this character that have been 
advocated is very large, but it is hardly accessary to describe 
them. A- has been mentioned, one may always sacrifice a less 



820 



oirniork'Dic swigxrv. 



important to a more important function, and as a weak muscle 
can hardly carry out its original function and a more important 
one as well it is advisable in most instances to relieve it com- 
pletely of the first in making the transfer. 

The Operation. The technique of the operation is simple. All 
restriction to normal motion must be overcome by manual force 
and, if necessary, by tenotomy as a preliminary measure. The 
operation should be performed under an Esmarch bandage. 
The incision should be long enough, as a rule, to expose the 



Fin. 507. 




Talipes equinovalgus after treatment by tendon transplantation. The tendon of the 
I eroneus tertius was attached to the overlapped and shortened tendon of the tibialis amicus. 
All the tendons on the front of the foot were then united, so that all might serve as dorsal 
flexors. 



muscular substance of the muscles and the point at which the 
transplanted tendon is to be attached. By exposing the parts 
one is able to verify the previous diagnosis. A completely par- 
alyzed muscle is atrophied and of a dull, red dish -yellow color, 
and its tendon is of a yellowish-white tinge. A partially paralyzed 
muscle is atrophied, its tendon is small, but it retains the silvery 
glisten of the normal structure. The tendon sheaths having 
been opened, the tendon is divided or split near its insertion, and 
the part to be transplanted is then placed in apposition to the 
tendon of the paralyzed muscle, whose surface has been freshened 



DEFORMITIES OE THE FOOT 821 

with the knife. The two are then attached to one another by 
several sutures of iine silk, and the graft is covered by uniting 
the tendon sheath or fatty tissue over it with Hue cat out. The 
skin incision is closed with a continuous catgut suture. It should 
he stated that the graft is applied under a certain tension, all the 
slack being drawn in, as it were, so that the foot is held if 
possible in the normal attitude. This is further assured in most 
instances by shortening the tendon of the paralyzed muscle. A 
plaster bandage is then applied in the overcorrected position, and 
in this attitude the foot should be used for many mouths. 

Modifications of the Operation. Since its introduction the oper- 
ation of tendon transplantation has been modified in several par- 
ticulars. It has been demonstrated by experience that there is 
a strong tendency toward relapse to the original condition, either 
because of weakness of the transposed muscles or because of 
displacement of the new attachments. This indicates the neces- 
sity of long-continued fixation in the overcorrected attitude and 
of subsequent support by braces until one is certain of the final 
outcome. 

It has been urged by Lange that the tendon of the living 
muscle should not be attached to that of the paralyzed one, but 
should be fixed directly to the periosteum at the point of greatest 
mechanical efficiency. If the tendon is not long enough for this 
purpose it should be lengthened by means of a silk cord incor- 
porated in its substance, about which it is assumed new tendinous 
material will form during its absorption. "Wolff has suggested 
implanting the end of the tendon beneath the cortex of the bone, 
and I have gone still further in the interest of security by boring 
a hole completely through the bone to which the attachment is to 
be made, passing the tendon through it and sewing it to itself 
and to the periosteum on the other side. Thus, in utilizing the 
extensor longus hallucis to replace the tibialis anticus the hole is 
made in the navicular. The tendon, having been divided about 
one inch from its insertion, is passed through and drawn tight 
enough to hold the inner border of the foot at a right angle to 
the leg. The tendon of the paralyzed tibialis antious ie then cut, 
overlapped, and sutured to aid in relieving the strain. [f the 
tibialis anticus muscle, on the other hand, is to be u-< <\ as an 
abductor it is split in the manner described, and as it is aot long 
enough for bone implantation a cord of Bilk is quilted into it and 

-- d through the cuboid, while the tendon itself is attached to 
>f the peroneus tertius and to the periosteum in the usual 



ORTHOPEDIC SURGEU V. 

manner. Silk may be depended upon to hold for about a year, 
although it is Dot completely absorbed for several years. For 
uniting adjacent tendons I prefer the continuous suture over a wide 
extent of surface. 

Tendon Transplantation in Combination with Other Procedures. 
A- the object of operative treatment is to prevent deformity and 
to increase the stability of the foot, tendon transplantation may 
be of greater service when combined with other operations. One 
of these lias been mentioned in the treatment of talipes cal- 
caneus. (See page SOS.) For valgus deformity arthrodesis of 
the astragalonavicular articulation in the attitude of adduction, 
and for varus in the position of abduction, are useful adjuncts. 
The operation is very simple. The joint is opened by a lateral 
or superior incision and the cartilage is removed with a knife or 
sharp chisel. As a rule, when the foot is forced into the over- 
corrected position the cut surfaces are fixed in apposition. 

The foot should be retained for several months in the over- 
corrected position in the plaster bandage, on which the patient 
walks about until the foot has become adapted to the new posi- 
tion. In many instances further support is unnecessary, but a 
brace should be used if there is a tendency toward deformity. 

The prognosis depends upon the degree of permanent paralysis 
and its distribution. It is, of course, evident that tendon trans- 
plantation is essentially a palliative rather than a curative opera- 
tion. In selected cases in which the attachment is directly to 
the bone, and especially when lateral motion is checked by 
arthrodesis, the results are very satisfactory. The improvement in 
functional ability is immediately shown in the improved circula- 
tion and size of the limb. In some cases of this class the 
transferred muscle is apparently undergoing an adaptive hyper- 
trophy. It is needless to say that such results are favored by 
massage and by appropriate exercises. Even in those cases in 
which the result is far from satisfactory, some improvement is 
usually apparent. 

Th<- principles of tendon transplantation may be applied in 
other situations. For example, the sartorius or the tensor vaginae 
femoris muscle may be attached to the tendon of a paralyzed 
quadriceps extensor muscle for the purpose of restoring in some 
degree the ability to extend the leg. 

The flexor muscles may be transplanted to the extensor aspect 
of the thigh to overcome persistent contracture, the result of 
spastic paralysis. ' s c ( - page 615.) 



DEFORMITIES OF THE FOOT ^2^ 

The operations for the relief of hemiplegic deformity of the 

hand have been mentioned. (See page (>13.) 

Tendon Splicing. Division and overlapping of the tendons of 
paralyzed muscles may be employed with advantage in certain 
instances. For example, in complete paralysis of all the dorsal 
flexors of the foot, each tendon may be shortened and attached 
to the anterior ligament; thus the toe-drop may be remedied or 
reduced to such an extent that the deformity may interfere but 
slightly with locomotion. As a rule, however, apparatus must 
be employed to prevent a recurrence of the deformity unless it 
be combined with arthrodesis. 

Arthrodesis. 

The removal of the cartilaginous surfaces of articulating bones 
and thus inducing anchylosis for the relief of paralytic deformi- 
ties of the foot, was first performed by Albert, of Vienna, in 
1878. As applied to the foot, it is of special service in those 
cases in which practically no muscular power remains, the so- 
called dangle-foot. It may be of service, also, in cases of 
less disability, as in equinus or calcaneus, when the patient is 
unable to provide himself with apparatus or desires to dispense 
with it. 

The operation consists in opening the joint and removing the 
cartilage from the apposed surfaces of the bones, then sewing or 
nailing them to one another, or simply fixing the parts in a plaster 
bandage until union has taken place. If the case is one of simple 
calcaneus or equinus, without lateral deviation, the operation 
may be limited to the ankle-joint, which may be opened from the 
back or front side, as seems preferable. A- has been stated, the 
usual incision is about two inches in length over the front of the 
ankle-joint. The foot is then plantar flexed and the cartilage is 
thoroughly removed from the articulating surfaces with a thin 
chisel or knife. The wound is then closed, and the denuded 
bones are forced into accurate apposition and fixed by a plaster 
bandage. As soon as possible the patient is i ocouraged t<» use 
the foot. A- a rule, in cases of complete paralysis of the anterior 
group simple anchylosis ;it the ankle-joint Is not sufficient t<- pre- 
vent the toe-drop, and ir is well to destroy the mediotareal joint 
also. A convenient method i- to remove the cartilaginous sur- 
face of the astragali navicular and calcaneocuboid articulations, 
together with a thin wedge of hone, base uppermost. In some 
instances the tendons of the paralyzed muscles are shortened to 



s_> i ORTHOPEDIC SURGE11Y. 

aid in retaining the foot in the improved position. This, how- 
ever, is of minor importance. The operation should be performed 
under the Esmarch bandage, and the limb should be elevated for 
a time to prevent the subsequent bleeding from the bones. 

Arthrodesis and Tendon Transplantation. As has been 
mentioned, arthrodesis may be combined with tendon transplanta- 
tion. For example, the astragalonavicular joint may be obliter- 
ated if the foot is inclined toward valgus, union being obtained in 
a position of adduction. Or, if the attitude is one of varus the 
foot must be held in abduction during the process of consolida- 
tion. In some instances the arthrodesis is obtained by removing 
a thin cuneiform segment from the inner or outer aspect of the 
foot, including the joint. In the treatment of varus deformity 
this may include the calcaneocuboid joint also. 1 The operation 
for the relief of calcaneus deformity has been described. (See 
page 80S.) 

The improvement in the gait, obtained by the rectification of 
deformity, and by fixation of the foot, after arthrodesis, is often 
very marked, and in many instances support may be discarded ; 
but, in early childhood at least, the patients should, if possible, 
be kept under observation, in order that recurrence of deformity 
may be prevented. 

Arthrodesis is also performed at the knee and at the elbow- 
joints and wrist-joints for the purpose of fixing the part in a useful 
attitude. The operation is, of course, limited to cases of hopeless 
paralysis, and it is more satisfactory to the older than the younger 
class of patients, because the liability to recurrence of deformity 
is less. Arthrodesis at the shoulder-joint is of service when the 
humeroscapular muscles are paralyzed, especially in those cases 
in which the oiuscles that move the scapula retain their power, 
Bince anchylosis adds to the effectiveness of the arm muscles. 
The joint may be opened by an incision along the anterior lower 
border of the deltoid. The cartilaginous surfaces are removed, 
and the humerus is then fixed in close contact with the glenoid 
surface of the scapula by a drill or by sutures until union is firm. 

i Whitman. Journal of American Orthopedic Association, 1903, No. 1, vol. i. 



INDEX 



ABDUCTION in extreme types of 
weak foot. 676 
Abduction in hip disease, 301 
Absence of clavicle, 233 
of ribs. 233 
of vertebra! 1 , 230 
Absent patella, 436 

treatment of, 436 
Abscess in acute osteomyelitis of 
spine. 130 
complicating tuberculous disease of 
spine in different re- 
gions, 106 
treatment of, 108 
as complication in tuberculous dis- 
ease of spine, 104 
statistics of, 104 
in different regions of spine, 106 
treatment of, 108 

aspiration in, 110 
injections in, 110 
pelvic, in tuberculous disease of 

lower region of spine, 44 
as secondary symptom in tubercu- 
lous disease of spine, 30 
in thoracic region in tuberculous 

disease of spine, 55 
in tuberculous disease of hip-joint, 
371 
statistics of, 371 
Koenig's, 372 
treatment of, 374 

exploratorv operation- in. 
376 
of knee-joint, 410 
statistics of. 410 
treatment of, 420 
Achillobursitis, 713 
anterior, 713 
etiology of, 713 
pathology of, 714 
posterior, 71 5 
symptoms of, 713 
Treatment of. 71 1 
operative. 7! 5 
Aehillodynia. See Aohillobursitia, 713 
Achondroj.! Chondrod 

phia, 402 
Acquired calcani <■■ alg u - 
treatment of, 812 
calcaneovarw- 

treatment of, 812 
cerebral parah r sis, 606-61 1 



Acquired luxation of the clavicle, 233 
treatment of. 233 
simple valgus, si \ 
talipes, 704 
calcaneus, S04 

development of deformity in, 

804 
symptoms of, 805 
t real men! of, 805 
operative, 807 

Whitman's operation, 810 
Willett's operation, 808 
equinovalgus. 813 
equinovarus, 812 
equinus, 706 
etiology of, 707 
prognosis of, 799 
symptoms of, 708 
treatment of, 700 
arthrodesis in. 803 
immediate corred ion of de- 
formil y in. sol 

tonic effect of, 801 

Shaffer extension shoe in. 

S(,ll 

torticollis, 631 
acute, 631 
Acromegalia, 500 

diagnosis of, 500 
Active congestion as means of treat- 
ment of joint affections, 261 
Acute acquired torticollis, 631 
anterior poliomyelil is, 583 

causes of deformity in, 590 
fund ional use, 591 
gravity, 590 
habil ual i«>-t lire, 591 
muscular act ion. 590 

BUbluxal ion. 591 

rmitiee of neck in, 
tidary, in 

of trunk in. 

of upper ext remity in. 

differential, 58' 
effect 

muscles upon fund ion 
etio 
patholog 

electi ical test in, 

P'ta- 






INDEX. 



\i-wir anterior poliomyelitis, statistics 
of (list ribui ion of paralysis, 
585 
Bymptoms «>i'. 585 
i real menl of, 595 

mechanical, principles of, 

595 
operat ive, 601 
.irt hrodesis in, 603 
osteotomy in, 60 1 
of paralysis of arm, (500 
of anterior lesj muscles, 

596 
of muscles of hip, 599 
of posterior Leg muscles, 

596 
of thigh muscles, 59S 
of paralytic scoliosis, 600 
tendon transplantation in, 
602 
Acute arthritis of infancy, 270 
etiology of, 270 
prognosis of, 271 
statistics of, 271 
symptoms of, 271 
treatment of, 271 
Acute epiphysitis at hip-joint, 392 
infectious arthritis of hip-joint, 

osteomyelitis, 272 
of spine, 130 

symptoms of, 130 
treat men! of, 131 
Acute tuberculous arthritis, 272 
Adduction in hip disease, 302 
Amputation in t uberculous disease of 

knee-joint, 423 
Anchylosis, 286 
etiology of, 286 
pathology of, 286 
prevent ion of, 286 
treatment of, 286 

cible correction in, 288 
pa—ive mot ion in, 2SS 
X-ray in, 289 
Ankle-joint, tuberculous disease of, 

no 
Ankle, sprain of, 450 
chronic. 153 

treatment of, 153 
symptoms of, 150 
treatment of, 150 
adhesive plaster in, 151 
Ankle, tenosynovitis at . 15 I 

treatment of, 155 
Ankle, tuberculous disease of, 1 10 
deformity of, I 13 
diagnosis of, 1 1 1 
pat bology of, 1 10 
physical examination in, | \:> } 
prognosis of, l I s * 

I 10 

ige, in 

- 1 Is 

;i of disease, 441 



Ankle, tuberculous disease of, statis- 
tics of, table of age at in- 
cipiency, 442 
subastragaloid disease, 444 
symptoms of, 442 
treatment of, 446 
operative, 447 
reduction of deformity in, 
446 
Anterior achillobursitis, 713 
bow-leg, 580 

displacement of the tibia. See 
( Ymgenital genu recurvatum, 434 
metatarsalgia, 704 
etiology of, 705 
influence of shoe in causing pain 

in, 708 
pathology of, 705 
treatment of, 710 
operative, 711 
Anterior poliomyelitis, acute. See 

Acute anterior poliomyelitis, 583 

Anterior shoulder brace in treatment 

of tuberculous disease of spine, 76 

Anteroposterior deformities of spine, 

224 

kyphosis, 224 

treatment of, 227 
lordosis, 228 

treatment of, 228 
Arborescent synovial tuberculosis, 

252 
Arthrectomy in treatment of tuber- 
culous disease of knee- 
joint, 420 
results of, 421 
statistics of, 421 
Arthritis, acute, of infancy, 270 
etiology of, 270 
prognosis of, 271 
statistics of, 271 
symptoms of, 271 
treatment of, 271 
infectious, of hip-joint, 392 
tuberculous, 272 
complicating infectious diseases, 
269 
prognosis of, 270 
spontaneous dislocation in, 

270 
treatment of, 269 
Arthritis deformans, 274, 396 
symptoms of, 397 
treatment of, 397 
gonorrheal, 267 
distribution, 267 

statistics of, 267 
of hip-joint, 394 
symptoms of, 267 
treatment of, 268 
varieties of, 268 
Arthritis of knee, infectious, 428 
of spine, infectious, 135 

treatment of, 135 
puerperal, 269 



IXDEX. 



82' 



Arthritis, rheumatoid. 279 
etiology of, 2S2 
treatment of, 2S2 
subacute, of hip-joint. 393 
Arthrodesis, description of operation, 
823 
for relief of paralytic deformities of 

foot, 823 
and tendon splicing. S24 
in treatment of acquired talipes 
equinus, 803 
of acute anterior poliomyelitis, 

603 
of rigid weak foot, 097 
Arthrotomy in treatment of congen- 
ital dislocation at hip, .Y27 
Astragalectomy in treatment of tal- 
ipes. 7S1 
Astragaloscaphoid joint, tuberculous 

disease of, 449 
Asymmetrical development, 234 
Ataxia, hereditary. 619 
Atrophy of bone, 241 

progressive muscular, 616 
in tuberculous disease of hip-joint, 
307 
Bracken's statistics of. 308 



BACK knee. See Genu recurvatum . 
432 
Back, lower part o'i, pain in, 144 
Bands, constricting, 793 
Baseball finger. See Mallet finger, 

484 
Bier's treatment of tuberculous dis- 
ease of joints, 259 
of knee-joint. 418 
Bilateral coxa vara, 541 

tuberculous disease of hip-joint, 
369 
treatment of, 369 
Billroth splint in treatment of tuber- 
culous disease of knee-joint. 414 
Bone, atrophy of, 241 
Bow-leg, 553 
anterior, 580 

symptom- o 580 
treatment of, 582 
etiology of, 554 

predisposition to deformity, 555 
outgrowth of deformity of, 557 
statistics of, '>'>■'> 

relative frequency of, ')'>'■'> 
table of, '>'> I 
treatment of, 558 
Brace in treatment of weak foot 

construction of, 6 
Bradford frame for horizontal ' 
tion in treatment o 
r|i-, tse, '' v 
modification i 
Bursa, enlargement of superficial pre- 
trial, 130 



Bursitis, chronic, at shoulder-joint, 

469 
gluteal. 395 
iliopsoas, 395 

treatment o\, 396 
prepatellar, o\ kraee, 129 

treatment of, 129 
pretibial, 429 

symptoms o\. 129 

treatment of, 430 



CA.LCANEOBURSITIS, 716 
treatment of, 710 
Calcaneovalgus, 789 
acquired, 812 

treatment of, 812 
Calcaneovarus, 789 
acquired, 812 
_ treatment of, 812 
Caliper brace in treatment of tuber- 
culous disease o\ knee-joint, 117 
Calot's operation of forcible reduc- 
tion of deformity 
of Pott's disease, 
123 
-elect ion of cases for, 

121 
statistics of results 
of, 120 
Caries sicca, 253 
Cavus, 789 

Cerebral paralysis of childhood. 606 
acquired. 611 

deformities of, ( il I 
disability in. 61 1 
Id-- of growth in. 61 I 
congenital weakness iii, 609 
deformil ies of, 610 
etiology of, 606 
prognosis of, 61 5 
statistics of distribution of, 

006 

symptoms of, 608 
' mental, 609 
motor, '''<> s 
t reat ment of, 61 2 
of hemiplegia, 612 
of paraplegia, 61 l 
variet ies of, 606 
acquired, 606 
congenital, 606 
cal "i»i-t hotonos, 6 16 
Charcot's disease, 28 1 
diagnoe 
distribution 
pat li"l<>!- r \ ol . 28 I 
statistii 

i reat mei 

minor, 2 

Hat 



828 



INDEX. 



Chest, funnel, 232 

p geon, 231 
i peat mem of. 231 
( !hondrodys1 rophia, 192 

etiology of, 192 

pal hology of, 192 

prognosis of. 19 I 

t real menl ot, 19 i 
Chronic bursitis at shoulder- joint, 

169 
Clavicle, absence of, 233 

acquired luxation of, 233 
t real menl of, 233 

detect of. 233 
Club-foot, hysterical, 621 

aon-deforming. See Contracted 

loot. 699 

Club-hand, 179 
ct iology of, 179 

-1 at LSI LCS Of, 17'.) 
treatment of, l s l 
\ ariet Les of. I7(> 
Congenital cerebral paralysis, 606 

cont racl i<>n of fingers, 482 
at knee, 439 

deformities at elbow, 477 
at wrist. I7't 
Congenital dislocation of hip, 502 
anterior, symptoms of, 511 
bilateral, symptoms of, 510 
diagnosis of, 511 

differential. 512 
ei iology of. •">(), 
pathology of, 503 
statistics of. 502 
supracotyloid displacement in, 
51 1 

symptoms of. 508 

general, 510 
t real menl of. 513 
;irt hrotomy in, 527 

descripl ion of, 527 
in infancy, 526 
Lorenz operal ion in. 514 
descripl ion of, 515 
prognosis of, 523 
of old.r subjects, 526 
open operal ion in. 530 
descripl ion of. 531 
statistics of. 532 
osteotomy in. 529 
palliat ive, 5:; I 
variation in. 527 
unilateral, Bymptoms ot . 508 
il dislocation of shoulder, 
17-' 

;• menl of. 172 
placemenl a of fingers, 183 

elevation of Bcapula, 228 

ral curvature of -pine. 1117 
- of. 1 67 

tali] 



Congenital calcaneus, 788 
equinovalgus, 789 
equinus, 788 
varus, 787 
torticollis, 626 
Congestion, active, as means of treat- 
ment of joint affections, 261 
passive, as means of treatment of 
joint affections, 259 
Constricting bands, 793 
Contour and flexibility of normal 
spine, 31 
of spine, variations in, 223 
Contracted foot, 699 
etiology of, 699 
symptoms of, 700 
treatment of, 702 
operative, 703 
Contractions, general, at knee, 439 
prognosis of, 439 
treatment of, 439 
Corsets in treatment of tuberculous 

disease of spine, 95 
Coxa valga, 552 
vara, 535 
bilateral, 541 

symptoms of, 541 
diagnosis of, 543 
etiology of, 537 

mechanical predisposition to 
deformity, 537 
other varieties of, 542 
pathology of, 536 
statistics of, 538 
symptoms of, 539 

mechanical effects, 539 
physical effects, 540 
traumatic, 548 
in adult life, 551 
treatment of, 550 
treatment of, 545 
operative, 546 

cuneiform osteotomy in, 547 
forcible abduction in, 546 
linear osteotomy in, 546 
Cretinism, 494 
Cubitus valgus, 477 

varus, 477 
Cuneiform osteotomy in treatment of 
coxa vara, 547 
of talipes, 782 
Cysts of femur, 396 
in popliteal region, 430 



DEFECT of clavicle, 233 
Depression of neck of femur. 
See Coxa vara, 535 
Development, asymmetrical, 234 

normal, table of, 235 
Diagnosis of acromegalia, 500 

of acute anterior poliomyelitis, 

586 
of Charcot's disease, 285 



INDEX. 



829 



Diagnosis of congenital dislocation at 
hip-joint, oil 
of coxa vara, 543 
differential, of lumbar Pott's dis- 
ease in infancy, 50 
of tuberculous disease of hip- 
joint, 319 
of disease of upper region in tuber- 
culous disease of spine, 61 
of joint disease, 256 
of lateral curvature of spine, 175 
posture in. 175 
mobility in, 175 
of malignant disease of spine, 130 
of pseudohypertrophic muscular 

paralysis, 618 
of sacro-iliac disease, 147 
of syphilis of spine, 129 
of torticollis, 635 

of tuberculous disease of ankle- 
joint. 444 
of knee-joint, 408 
of spine, 46-64 

Roentgen rav as means of, 
65 
of weak foot, 672 
Diphtheritic paralvsis with torticollis, 

646 
Diseases of nervous system, 583 

statistics of, 583 
Dislocation, spontaneous, in arthritis 
complicating infectious dis- 
eases, 270 
of hip-joint, 393 
Displacement of the peronei tendons, 
727 
treatment of, 727 
of semilunar cartilage, 431 
treatment of, 432 
Distortions of fingers, 483 
general rhachitie. 582 
of limb in tuberculous disease of 
hip-joint, 301 
Divisions of spine, 32 
of tendo Achillis in treatmenl of 
talipes, 77:-! 
Dollinger's statistics of retardation of 
growth in tuberculous disease 
of hip, 311 
of situation of tuberculous dis- 
ease of spine, 2 1 
Drop-finger. Set Mallei finger, I s - 1 
Dry caries, 253 
Dupuytren's contraction, 184 
etiology of, 185 
pathology of. is 1 
symptoms ol . i s "< 
treatmenl of, i s "> 
1 » si rophy, muscular, 'il 7 



ELBOW, congenita] deformities at, 
477 
Elbow, tuberculous d 160 

-joint, tuberculous di« 



Elbow-joint, tuberculous disease of, 
pathology o\, 160 

prognosis (if, 162 
statistics of, 160 

age at incipiency, 161 
symptoms of 1 , Mil 
treatment of, 461 
excision in. 46 1 

Statistics of final results. 
164 
operative, 464 
reduction of deformity in, 
462 
Elongation of ligamentum patella?, 
438 
etiology of, 438 
symptoms of, 438 
treatment of. 438 
Enlargement of superficial pretibial 

bursa, 430 
Epiphysitis, acute, at hip-joint, 392 
symptoms of, 392 
treatment of, 392 
Equinovalgus, traumatic, 814 
Erythromelalgia, 717 
Excision of elbow in tuberculous dis- 
ease of elbow-joint, 464 
in tuberculous disease of knee- 
joint, 422 
results of, 423 
statistics of, 423 
Exostoses of foot, 727 
Extra-articular disease, 395 
of knee, 419 



FEET, congenital oedema of. 793 
Femur, bending of neck of. S( ■ 
Coxa vara, 535 
Femur, cysts of, 396 

depression of neck of. Sea Coxa 

vara, 535 
fracture of neck of, in adult life, 
:,:,1 
Finger, " baseball." Set Mallei fin 
ger, 184 

congenital COnl ract ion of, 182 

t real menl of, 182 
displacement a of. 
distort ion- of, l s '> 
drop. See Mallet finger, I s i 
jerking. Set Trigger finger, 183 
mallet, 184 
snapping 
trigger, 183 
webbed, 182 
et iology of, \^'< 
t real mi nt 
Flat chest, 230 
treatmenl ol 
} 
Foetal rhachiti* 

tropin:,. 
. 

arch< 






INDEX. 



Fool considered as a mechanism, 
tit in 
contracted, 699 
el iology of, 699 
Bymptoms of, 700 
treatment of, 702 
operative, 703 
Fool exostoses of, 727 
flat. 8& Weak foot, 664 

fund ions of muscles of, i>"> s 

general description of, 6 17 
hollow. St < Contracted toot, 000 
improper postures of, 651 
movements of, 651 
as a passive support . 049 
Foot, rigid, 690 

treal menl of, 690 
forcible overcorrection in, 690 
manipulation in, 693 
varieties of, 695 
t real ment of, 096 
operal ive, 007 
plaster st rapping in, 696 
Thomas', 696 

arthrodesis in, 697 
splay, S< < Weak foot . 004 
tables of relative strength of mus- 
cles of, 659 
weak, 66 1 

anatomy of, 664 

in childhood, 678 

symptoms of, 678 
diagnosis of, 672 
et iology of, 669 
ex1 reme types of, 676 

persistenl abduction in, 676 

pes planus, (i70 

irregular tonus of, 680 
limitation of motion and muscu- 
lar spasm in. 676 
pathology of, 60S 
Btal i-' ics of, 669 
symptoms of, 670 

t real ment of, 6X2 

attitudes in, 683 
brace in, 685 

const ruction of, 685 
exercises in, 68 I 

the -hoc in. 682 

SUpporl in. 68 | 

varieties of. 675 
Forcible manual correction of de- 
formity of talipes, 7<i:; 

■ eorred ion in i real ment of rigid 

\\«-;,k loot. 690 

lire "i metatarsal bones, 727 
<.i neck of femur. Set Traumal ic 
coxa \ ara, ■"> I s * 

in adult life. ",1 
.in. 195 

,619 
Functional affections of joint. 022 

It lorinit v, 235 
Funnel chi si 232 



GENU varum, 575 
symptoms of, 576 
Genu varum, treatment of, 578 
by braces, 578 
expectant, 578 
operative, 579 
Gluteal bursitis, 395 
Gonorrhoea!, arthritis, 267 
distribution, 267 

statistics of, 267 
of hip-joint, 394 
symptoms of, 267 
treatment of, 268 
varieties of, 268 
rheumatism. See Gonorrhosal ar- 
thritis, 267 
Gout, rheumatic, 274 
Grattan osteoclast in treatment of 
talipes, 778 



H^EMARTHROSIS, 283 
Hemophilia, 283 
Haemophilia, treatment of, 283 
Hallux flexus. See Hallux rigidus, 718 
rigidus, 718 

etiology of, 718 
treatment of, 719 
Hallux valgus, 722 
etiology of, 722 
pathology of, 722 
symptoms of, 723 
treatment of, 723 

Holden toe-post in, 723 
operative, 725 
Hallux varus, 720 

treatment of, 721 
Hammer-toe, 725 
symptoms of, 726 
treatment of, 726 
Heberden's nodosities in osteoarthri- 
tis, 278 
Heel, painful, 716 
Hemiplegia, treatment of, 612 
Hereditary ataxia, 619 
High hip in lateral curvature of the 
spine, 156 
shoulder in lateral curvature of 
spine, 156 
Hip, congenital subluxation of, 534 
Hip disease. See Tuberculous disease 
of hip-joint, 291 
hysterical, 620 

-joint, acute infectious arthritis of, 
392 
epiphysitis at, 392 
symptoms of, 392 
treatment of, 392 
congenital dislocation at, 502 
anterior, symptoms of, 511 
bilateral, symptoms of, 510 
etiology of, 507 
diagnosis of, 511 
differential, 512 



INDEX. 



831 



Hip-joint, congenital dislocation at, 
pathology of, 503 

statistics of, 502 

supra cotyloid displacement 

in, oil 
symptoms of, 508 

general. 510 
treatment of, 513 
arthrotomy in. 527 

description oi. 527 
in infancy, 526 
Lorenz operation in, 514 
description of, 515 
prognosis of, 523 
of older subjects, 520 
open operation in. 530 
description of. 531 
statistics of, 532 
osteotomy in, 529 
palliative, 534 
variations in. 527 
unilateral, symptoms of, 508 
gonorrhccal arthritis of, 394 
malignant disease about, 396 
osteo-arthritis of. 396 
symptoms of. 397 
treatment of, 397 
snapping, 535 

spontaneous dislocation of, 393 
subacute arthritis of, 393 
traumatism at, 391 
treatment of, 391 
Hip, tuberculous disease of, 291 
abscess in, 371 

significance of, 373 
statistics of, 371 
Koenig's, 372 
treatment of. 374 

exploratorv operations in, 
376 
actual lengthening of limb in. 
313 
shortening of limb in, 309 
in the adult, 371 
atrophy in. 307 

Bracken's statistics of, 308 
bilateral. 369 

treatment of, 369 
changesof contour of hip in,306 
combined with disease of other 

parts. 370 
correction of deformity by 

femoral osteotome 
deformities of other parts 

caused by, 389 
detail of 1000 cases of, 32 1 
diagnosis of, differential, 3 1 9 
anterior poliomyelitis in. 319 
coxa vara in. 321 
disease of bursa? about joint 

in. 321 
epiphysitis in. 320 
extra-articular disease in. 
- 



320 
n.320 



321 

321 



Hip, tuberculous disease of. diagnosis 
o\\ differential hysterical 
joint in. 322 
infectious arthritis in 
osteo-arthritis of hip 
Pott's disease in. 321 
rheumatism in. 320 
sacro-iliac disease in. 
scurvy in. 320 
traumatic coxa vara in 
X-ray as means of. 322 
distortion o\ limb in. 301 
apparent Lengthening, 301 
shortening. 302 
etiology of. Si e 2 13 
examination in. met hod of, 313 

physical. 314 
excision of hip in, 377 

Koenig's method. 377 
statistics of. 379 

table of functional re- 
sults, 3S0 
general symptoms of, 313 
debility as. 313 ' 
fever as, 313 
history of case of. 313 
in infancy. 370 
Koenig's statistics of, 304 
local signs of, 318 
measurements of, 315 
method of estimating degree 
of distortion of t he 
limb. 316 
Lovetrs table, 316 
Kingsley's table, 31 s 
of recording case of, 322 
formula used. 323 
mortality in. 38 1 
statistics of. 384 

causes of deal h. 385 
•• natural cure" in. 303 
pathology of. 291 
prognosis of, 38 I 
a- to function. 387 
stat istics "i . 387 
reduction of deformity in re- 
sistant cases of, 381 
relative frequency of, 295 

statistics of, 295 
retardal ion of growl b in. 31 1 
Ddllinger's statistic* of, 

311 
Taylor's statistics of, 312 
sinuses in. :;7"> 

t reatment 
stat 

side affected, 
symptom 

' limp a-. 298 
•• night ■ -"'< 

paw 

Btii 
tment of, 



S32 



INDEX. 



Hip tuberculous disease of, treatmeni 
of, applical ion of spica 
bandage, 345 
of traction splint in, 331 
during St age Of recovery, 363 
immediate reduction of de- 
formity in. 348 
Judson's perineal crutch in, 

365 
Lorenz's spica in, 347 
mechanical, 327 
high shoe in, 331 
perineal bands in, 331 
splinting in, 327 
traction in, 327 
hip splint for, 327 
straps tor, 329 
Taylor's method of, 329 
by plaster bandage, 345 
practical combination trac- 
tion, stilting, and splint- 
ing, 356 
reduction of deformity, lat- 
eral traction in, 353 
by Marsh's appliance 

for, 351 
bv Thomas' method, 

"342 
by traction brace, 333 
by weights and pullevs, 
"350 
relative efficiency of trac- 
tion hip splint, 334 
traction and splinting, 
354 
Taylor's median abduction 

brace in, 364 
Thomas, 338 
brace in, 339 

modifications of, 343 
Holden toe-post in treatment of hal- 
lux valgus, 723 
Hollow toot. See Contracted foot, 

699 
Horizontal fixation in treatment of 
tuberculous disease 
ni spine, 67 
Bradford frame for, 68 

modifical ion of, 69 
Lorenz apparatus for, 

67 
Phelps' bed tor, 68 
win- cuirasse lor, 68 
Housemaid's knee, 129 
ricaJ club-foot, 621 
deformil ies, ( '»2l 
hip. 620 
diagnosis of. 620 

joint affeci ion-, 619 

-<■<.! io-;~. 621 

treatmeni of, 621 

\. . 11:; 

Bymptoms ol . I 13 
t reatmenl of, I \ \ 



IDIOPATHIC osteopsathyrosis, 495 
Iliopsoas bursitis, 395 
treatment of, 396 
Incurvation of neck of femur. See 

Coxa vara, 535 
Infantile paralysis. See Acute ante- 
rior poliomyelitis, 583 
scorbutus, 494 
pathology of, 494 
symptoms of, 494 
treatment of, 495 
talipes, 749 
: . Infectious arthritis of knee, 428 
of spine, 135 

treatment of, 135 
Injury of knee in childhood, 427 
of spine, 131 
of tibial tubercle, 430 
Internal derangement of knee-joint, 

430 
Irregular forms of weak foot, 680 



JERKING finger, 483 
Joint affections, hysterical, 619 
Joints, neurotic, 622 

functional affections of, 622 
syphilitic diseases of, 263 

gonorrhceal arthritis, 267 
distribution, 267 

statistics of, 267 
symptoms of, 267 
treatment of, 268 
varieties of, 268 
puerperal arthritis, 269 
treatment of, 265 
Judson brace in treatment of talipes, 

754 
Julius Wolff's method of treatment of 

talipes, 774 
Jury mast in treatment of tubercu- 
lous disease of spine, 86 






KINGSLEY'S table for estimating 
degree of distortion in tuber- 
culous disease of hip -joint, 
318 
Knee, back. See Genu recurvatum, 
432 
bursa? at, 430 

congenital contraction at, 439 
cysts at, 430 
deformities of, 434 
displacement of a similunar cartilage 
in, 431 
injury as cause of, 431 
treatment of, 432 
Knee, general contractions at, 439 
prognosis of, 439 
treatment of, 439 
• ■nlargement of superficial pretibial 

bursa of, 430 
housemaid's, 429 



IXDEX. 



833 



Knee, infectious arthritis of, 42S 
injury of, in childhood, 427 
injury of tibial tubercle. 430 
Knee-joint, loose bodies in. 431 
internal derangement of, 430 
non-tuberculous affections of 

427 
malformations of, 434 
etiology of, 435 
treatment of, 435 
osteo-arthritis of, 428 

treatment of. 42S 

prepatellar bursitis oi, 429 

treatment of, 429 

Knee, pretibial bursitis of, 429 

symptoms of, 429 

treatment of, 430 

snapping, 43S 

treatment of. 439 
synovitis of. 427 
chronic, 428 
treatment of, 427 
Knee, tuberculous disease of, 399 
abscess in. 419 
statistics of, 419 
treatment of, 420 
actual lengthening of limb in, 
407 
statistics of, 408 
shortening of limb in, 407 
statistics of, 407 
arthrectomv in treatment of, 
420" 
results of, 421 
statistics of, 421 
diagnosis of, 408 

differential, 408 
distortions of, primary, 404 

secondary, 405 
etiology of, 401 
operations for relief of final 

deformity, 423 
pathology of, 399 
prognosis of, 423 

statistics, course, and out- 
come of, 423 
Gibnev's, 423 
of results. 424 
statistics of, 401 

age at incipiency, 402 
symptoms of, 402 

vial tuberculosis in, 420 
" treatment of, 120 
treatment of, 1"'< 
accessory, 117 

Bier's treatment, 418 

cautery a-. 117 

ichthyol ointment as, 

117 
X-ray as, 11 7 
amputation in. 123 
Billroth splint in, 113 
caliper brace in, 1 1 7 
during convalescence, 1 1 s 



Knee. tuberculous disease of, treat- 
ment o\. excision in. 122 
n-suhs of, 12:; 
statistics of. 123 
forcible correction by re- 
verse leverage, 1 1 2 
mechanical. 1 1 I 
operative intervention in, 

419 
plaster bandage in. 1 1 1 

reduction of deformity in. 

410 
Thomas knee brace in. 414 
traction in. 412 
Knock-knee, 553 

combined with bow-leg, 565 

with general rhachitic distor- 
tions, 565 
effects of deformity o\\ 50 1 
etiology of, 554 

predisposition to deformity in, 
555 
measurements of deformity in. 567 
outgrowth of deformity of. .v>7 
pathology of. 566 
secondary deformities accompany- 
ing, 564 
statistics of. 553 

relative frequency of, 553 
table of, 554 
time of onset, 55 1 
treatment of, 567 
by braces, 570 
duration of, 571 
exercise in, 569 
expectant, 567 
Lorenz's, 575 
manipulation in, 568 
operative, 572 
osteoclasis, 573 
osteotomy in, 572 
cuneiform, 573 
plaster bandage in. 572 
posture in, 569 
Thomas brace in, 570 
Wolffs, 57 1 
unilateral. 565 
Kyphosis of adolescents, l 1 1 

L\\II\].< T< >MY in treatment of 
Pott's paraplegia, 1 L8 
Laminectomy in treatment <-i Pott's 

paraplegia, Bta1 of, 118 

Landmarks ol apin< , 3 I 
Late rickets, 192 
Lateral curvature ■ : (9 

changes in anteropo 

1 our in. I 55 

compensatory deformity in, 

L65 
congenital, 161 

cases of, 1 67 



58 



83 I 



INDh'X. 



Lateral curvature of spine, diagnosis 

of mobility in. 1 7"> 

posl ure in, 1 75 
iluc to occupation, 1 (><» 
el iology of, l <»l 
hereditary influence in, 169 
high hip in, 156 

shoulder in, 156 
incidental, 1 ('>•'> 
lateral deviation in, 153 
Occupation as inducing de- 
formity, 170 
statistics of, 170 

pathology of. 156 

prevention of deformity in, 180 

prognosis of, 177 

records of, 177 

rhachitic, 168 

statistics of, 169 
rotation in, 153 
secondary to deformity else- 
where, 165 
to disease within thoracic 

walls, 166 
to paralysis, 166 
statistics of age in, 163 

of relative frequency of, 161 
of sex in, 162 
symptoms of, 174 
treatment of, 181 
duration of, 221 
exercises in, 185-201 
muscle building, 209 
Teschner's, 187 
forcible correction of de- 
formity in, 217 
general, 221 
high shoe in, 221 
posture in, 185 
volkmann seat in, 221 
varieties of deformity in, 173 
Ligamentum patella?, elongation of, 
138 
etiology of, 438 
symptoms of, 138 
treatment of, 438 
Linear osteotomy in treatment of 

coxa \ ara, obi 
Loose bodies in knee-joint . 431 
Lorenz apparatus for horizontal fixa- 
tion in treatment of Pott's dis- 
ease, 67 
operal ion for congenital dislocal ion 

:.t hip. 51 1 

i bandage in treatment of tu- 
berculous disease of hip-joint, 

it tnenl of knock-knee, 575 
table for est unat ing degree 
-tort ion in t uberculous disease 
of hip-joint. 316 
Lumbar Pott's disease in infancy, 
peculiaril ies o 

gnosis, differential, of, 50 



MALFORMATIONS of knee, 434 
etiology of, 435 
Malformations of knee, treatment of, 

t35 
Malignant disease about hip-joint, 396 
of spine, 129 

diagnosis of, 130 
statistics of, 129 
Malleotomv in treatment of talipes, 

772 
Mallet finger, 484 

Marsh's appliance for reduction of de- 
formity in tuberculous disease of 
hip-joint, 351 
Metatarsal bones, fracture of, 727 
Metatarsalgia, anterior, 704 
etiology of, 705 
influence of shoe in causing pain 

in, 708 
pathology of, 705 
treatment of, 710 
operative, 711 
Metzger-Goldthwait apparatus for 
correction of deformity of Pott's 
disease, 123 
Mollities ossium. See Osteomalacia, 

496 
Morbus coxsp. See Tuberculous dis- 
ease of hip-joint, 291 
Morton's neuralgia. See Anterior 

metatarsalgia, 704 
Muscles, pectoral, defective forma- 
tion of, 233 
Muscular dystrophy, 617 
Myelopathic paralysis, 616 
M}ropathic paralysis, 617 



;i "]VTATURAL cure" in tuberculous 

JJN disease of hip-joint, 303 
Nervous system, diseases of, 583 
Neuralgia, plantar, 717 

treatment of, 717 
Neuritis, 619 
Neurotic joints, 622 
spine, 142 

symptoms of, 143 
treatment of, 143 
Non-deforming club-foot. See Con- 
tracted foot, 699 
Non-tuberculous affections of knee- 
joint, 427 
deformities of knee-joint, 427 



OBSTETRICAL paralysis, 473 
treatment of, 474 
Ocular torticollis, 646 
( fsteitis deformans, 141, 498 
Osteo-arthritis, 274 
etiology of, 277 
Heberden's nodosities in, 278 
of hip-joint, 396 
symptoms of, 397 






IXDEX. 



s;5o 



Osteo-arthritis of hip-joint, treatment 
of, 397 
of knee. 42S 

treatment of, 428 
pathology oi. 275 
symptoms of, 277 
treatment of, 279 
Osteoclasis in treatment of knock- 
knee. 573 
Osteoclasts in treatment of talipes, 

77s 
Osteomalacia, 496 
in childhood, 497 
local. 497 
treatment of, 497 
Osteomyelitis, acute, 272 
of spine, acute, 130 
symptoms of, 130 
treatment of, 131 
subacute, 273 
Osteotomy, cuneiform, in treatment 
of knock-knee, 573 
in treatment of congenital disloca- 
tion of hip, 529 
of knock-knee, 572 
Overlapping toes, 727 



PAGET'S disease, 141 
Painful great toe-joint, 719 
Painful heel, 716 

Paralysis, cerebral, of childhood, 606 
* acquired, deformities of, 611 
disability in, 611 
loss of growth in, 611 
congenital weakness in, 609 
deformities of, 610 
etiology of, 606 
prognosis of, 615 
statistics of distribution of, 606 
symptoms of, 608 
" mental, 609 
motor, 608 
treatment of, 612 
of hemiplegia, 612 
of paraplegia, 614 
varieties of, 606 
acquired, 606 
congenital, 606 
Paralysis complicating tuberculous 
disease of spine, 111 
duration of, 114 
frequency of, 112 
liability to, in different re- 
gions, 113 
prognosis of, 1 1 6 
symptoms of, 1 1 1 
time of i 1 13 

treatment of, 11 6 
flnratir.ii. 126 

local, 119 
operat Lve, 1 1 7 
laminectomy, I I N 
diphtneritie, with torticollis, 646 



Paralysis, infantile. Se< Acute ante- 
rior poliomyelit is. 583 
myelopathic, 616 
myopathic, 617 
obstetrical, -4 73 

treatment of, 17 ! 
pseudohypertrophic muscular, 618 
diagnosis ot, 618 
t reatment of, 619 
as secondary symptom in tubercu- 
lous disease of spine, 30 
spastic spinal, 616 
Paralytic talipes, tendon transplan- 
tation for relief of, 815 
time for operation, 815 
torticollis. 6 15 
Paraplegia, treatment of, 614 
Partial epiphyseal separation in ado- 
lescence, 551 
Passive congestion as means of treat- 
ment of joint affections, 259 
Patella, absent, 436 

congenital displacement of, 436 
rudimentary, 436 
slipping, 436 
etiology of, 436 
symptoms of, 436 
treatment of, -137 
operative, 437 
Pectoral muscles, defective forma- 
tion of, 233 
Pectus carinatum. See Pigeon chest, 
231 
excavatum. See Funnel chest. 232 
Pelvic abscess, differential diagm 
of, 49 
in tuberculous disease of lower 
region of spine, -14 
Periarthritis of shoulder, 168 
symptoms of, 168 
treatment of, 169 
Peronei tendon-, displacement of, 
727 
treatment of, 728 
Pes planus, 676 

Phelps' bed for horizontal fixation in 
treatment of Pott's disease, 68 
operation in treatment "i talipes, 

77^ 

Pigeon chest . 231 

treatment of, 231 
toe, 721 
Plantalgia, 717 
Plantar neuralgia, _< 17 

t peat men) of, / 1 7 

Plaster bandage in treatment of in- 
fantile talipes, 75i 

of knock-knee. 572 

of tuberculous disease of kn 

joint .111 
Of lop-joint . 

spica, Lorenz, in treatment of tu- 
berculo iotj 

347 



836 



INDEX. 



Plaster corset in treatmenl of tuber- 
culous disease of spine, 92 
jacket in t real incut of Pott's dis- 
ease, 82 

application of, in recum- 
bency, 89 
modifications of, 93 

b1 rapping in treatmenl of weak foot, 
696 
Poliomyelitis, acute anterior, 583 
causes of deformity in, 590. 
functional use, 591 
gravity, 590 
habitual posture, 591 
muscular action, 590 
subluxation, 591 
deformities of neck, 592 
secondary, 593 
of trunk, 592 
of upper extremity in, 592 
diagnosis of, 586 

differential, 587 
effects of paralysis of differ- 
ent muscles upon function, 
589 
etiology of, 584 
pathology of, 583 
prognosis of, 588 

elect rical test in, 588 
retardation of growth in, 594 
statistics of age at onset of, 
584 
of distribution of paralysis, 
585 
Bymptoms of, 585 
treatment of, 595 

mechanical principles of, 595 
operative, 601 

arthrodesis in, 603 
osteotomy in, 604 
tendon transplantation in, 
602 
paralysis of anterior leg 

muscles, 596 
of paralysis of the arm, 600 
of paralysis of muscles of 

the hip, 599 
of paralysis of posterior leg 

muscles, 596 
of paralysis of thigh mus- 
cles. 598 

Of paralyt ic scoliosis, 600 

Posterior acnillobursil is, 715 
Pott's disease, 1 7 

characteristic angular deformity 

in. 17 
complical ions of, 1 1 
abscess, 104 

in different regions, 106 
statistics of, 104 
treatment of, 108 
aspiration in, 110 

injection in, 110 
paral) sis, ill 



Pott's disease, complications of, par- 
alysis, duration of, 114 
frequency of, 112 
liability to, in different re- 
gions, 113 
prognosis of, 116 
symptoms of, 114 
time of onset of, 113 
treatment of, 116 
local, 119 
operative, 117 

laminectomy, 118 
description of, 1 7 
diagnosis of, in general, 64 

Roentgen ray in, 65 
examination in, regional, 38 

tests in, 37 
history of patient having, 36 
later effects of deformity of, 127 
in lower region, 38 

characteristic attitude in, 39 
diagnosis of, 46 
differential, 46 

congenital dislocation 

of hip, 47 
hip disease, 48 
lumbago, 46 
sacro-iliac disease, 46 
sciatica, 46 
strain of the back, 46 
increased lordosis in, 39 
lateral inclination of body 

in, 40 
location of pain in, 40 
pelvic abscess in, 44 
psoas contraction in, 40 
Pott's disease, pathology of, 18 
prognosis of, 25 
record of case of, 65 
recurrence of, 127 
relative frequency of, 22 

statistics of, 22 
secondary deformities of, 127 
signs of, physical, 36 

rational, 35 
statistics of age at incipiency of, 
22 
Bollinger's, 24 
of relative frequency of, in 

different vertebra?, 24 
results of Calot's operation, 

120 
sex in, 23 

situation of disease, 23 
symptoms of, 26 
awkwardness as, 28 
deformity as, 28 
diagnostic, 27 
general, 31 
pain as, 27 
secondary, 30 
abscess, 30 
paralysis, 30 
stiffness as, 28 



INDEX. 



837 



Pott's disease, symptoms o\. weakness 

as. 28 
Pott's disease of thoracic region, 51 
abscess in, 55 
attitudes in. 52 
diagnosis of, 55 

differential, 56 
kyphosis in. 54 
muscular spasm in, 54 
respiration in. 52 
treatment of, 66 

ambulatory supports in, 74 
anterior shoulder brace in, 

76 
corsets, 95 
jury mast, 86 
plaster corset, 92 
jacket, 82 

application of, in re- 
cumbency, 89 
modifications of, 93 
Taylor brace, 74 

head support, 81 
Thomas' collar in 96, 
Weigel's corset, 95 
duration of, 126 
forcible correction of deform- 
ity of, 119 
Calot's operation, 119 
selection of cases for, 121 
gradual correction of deform- 
ity of, 123 
Goldthwait's method, 

123 
Metzger-Goldthwait ap- 
paratus for, 123 
horizontal fixation in, 67 
Bradford frame for, 68 
Lorenz apparatus for, 67 
Phelps' bed for, 68 
Wire cuirasse for, 68 
modifications of, 69 
indications for. by r<<umben- 
fv. 98 
special, of different region-. 
99 
of lower region of -pine, 100 
dorsal region of spine, 101 
mechanical, general principles 

of, 66 
of middle cervical r'jrion of 

spine, 102 
of middle region of spine, 102 
of occipito-axoid region of 

spine, 103 
of upper dorsal region of spine, 
102 

Eise of upper region, 57 
cervicodorsal junction, '»" 
diagnosis of. •»] 
Lower cervical Bed ion, 59 
occipito-axoid section, 58 
symptoms 
Pott's fracture. 81 » 



Prepatellar bursitis vA knee, 129 

treat meat o\, 129 
Pretibial bursitis, 129 

symptoms of. 12'.) 

treatment of, 430 

Progressive muscular atrophy, 616 
varieties of. til (i 
myelopathic, 616 
myopathic, 61 7 

muscular dystrophy, 617 
Pseudohypertrophic muscular paral- 
ysis, 618 
Psychical torticollis, Obi 
Puerperal arthritis, 2(1!) 



RECURRENT dislocation of shoul- 
der, 476 
Recurrent dislocation of shoulder, 
treatment of, 476 
operative, 476 
Retardation of growth in acute ante- 
rior poliomyelitis, 594 
Retrocalcaneobursitis. See Achillo- 

bursitis, 713 
Rhachitic distortions, general, 582 
lateral curvature of spine, 168 

statistics of, 169 
spine, 133 

natural cure of, 133 
treatment of, 133 
torticollis, 646 
Rhachitis, 486 
etiology of, 486 
foetal, 492 
prognosis of, 490 
symptoms of, 487 

deformities as, I s -? 
treatment of. I'.tl 

prevention of deformity in, 492 
Rheumatic gout. 27 1 
Rheumatism, gonorrhoea!. See Gon- 

orrhoeal arthritis, 267 
Rheumatoid arl hritis, 279 
etiology of, 282 
treatmenl of, 282 
llil.-. absence of. 233 
Mice bodies in t uberculous joint dis- 
ease, 253 
Rickets. Se< Rhachitis, 186 
late, 192 

scurvy. See [nfantile scorbutus 
[94 
Rigid \vak !<..,t, 690 

treatment of. 690 
forcible overcorrection in, 

manipulation in. I 
variet i< 
treatmenl of, 
operal h i 

arthrodesis ii 
plaster strapping in. I 
Tic 



338 



INDEX. 



Roentgen raj as means of diagnosis 
in tuberculous disease o\ spine, 65 

Rotary lateral curvature OI spine. 

l 19 
Rudimentary patella, 436 
breatmenl of, 136 



SA.CRO-ILIAC articulation, injury 
of, 148 
3acrO-iliaC disease, 146 
diagnosis of, 1 17 
prognosis of, 147 
symptoms of, 146 
treatment of, 147 
Scapula, congenital elevation of, 228 
Sciatic scoliosis, 145 
Sciatica, deformity secondary to, 145 
Scoliosis. See Lateral curvature of 
spine, 149 
hysterical, 621 
treatment of, 621 
Scorbutus, 284 
infantile, 494 
Scurvy, 2S4. 494 

Secondary deformities accompanying 
knock-knee, 564 
hypertrophic osteo-arthropathy, 
'499 
Septic infection in tuberculous joint 

disease, 253 
Shaffer extension shoe in treatment 

of acquired talipes equinus, 800 
Shoes, 728 

in treatment of weak foot, 682 
Shoulder, congenital dislocation of, 
472 
treatment of, 472 
Shoulder-joint, chronic bursitis at, 
469 
periarthric is of, 468 
Bymptoms of, His 
treatment of, 469 
recurrent dislocation of, 476 
treatment of, 476 
operative, 176 
tuberculous disease of, 457 
pathology of, loT 
prognosis of, 460 
Bta1 isl LCS of, l-")7 

age at incipiency of, 458 
symptoms of, 158 
t real menl of, 159 
operative. 160 
Slipping patella, 436 
Snapping finger, 183 
hip. 535 
knee, 138 
Socks. 

Spasmodic torticollis. See Torticollis, 
ismodic, 6 10 
ic spinal paralysis, <>1 6 
Spina binds and talipes, 793 
166 



Spina ventosa, statistics of, 467 
Spine, actinomycosis of, 131 
acute osteomyelitis of, 130 
symptoms of, 130 
treatment of, 131 
anteroposterior deformities of, 224 
kyphosis, 224 

treatment of, 227 
lordosis, 228 

treatment of, 228 
contour and flexibility of normal, 

31 
divisions of, 32 
hysterical, 143 
symptoms of, 143 
treatment of, 144 
infectious arthritis of, 135 

treatment of, 135 
injury of, 131 
landmarks of, 34 
lateral curvature of, 149 
cases of, 167 
changes in anteroposterior 

contour in, 155 
compensatory deformity in, 

165 
congenital, 167 
diagnosis of, 175 
posture in, 175 
mobility in, 175 
due to occupation, 166 
etiology of, 161 
hereditary influence in, 169 
high hip in, 156 

shoulder in, 156 
incidental, 166 
lateral deviation in, 153 
occupation as inducing de- 
formity, 170 
statistics of, 170 
pathology of, 156 
prevention of deformity in, 

180 
prognosis of, 177 
records of, 177 
rhachitic, 168 

statistics of, 169 
rotation in, 153 
secondary to deformity else- 
where, 165 
to disease within thoracic 

walls, 166 
to paralysis, 166 
statistics of age in, 163 

of relative frequency of, 161 
of sex in, 162 
symptoms of, 174 
treatment of, 181 
duration of, 221 
exercises in, 185-201 
Teschner's, 187 
muscle building, 209 
forcible correction deform- 
ity in, 217 



IXDEX. 



839 



Spine, lateral curvature oi, treatment Spine 
of. general. 221 
high shoe in. 221 
posture in. 185 
Volkmann seat in. 221 
varieties of deformity in, 173 
Spine, malignant disease of, 129 
diagnosis of. 130 
statistics of, 129 
neurotic, 142 

symptoms of, 143 
treatment of. 143 
osteo-arthritis of. See Spondylitis 

deformans. 135 
rhachitic. 133 

natural cure of. 133 
treatment of. 133 
rheumatism of. See Spondylitis 

deformans. 135 
syphilis of, 129 

diagnosis of, 129 
tabetic deformity of, 142 
Spine, tuberculous disease of, 17 
complications of, 104 
abscess, 104 

in different regions. 106 
statistics of, 104 
treatment of, 108 
aspiration in. 110 
injection in, 110 
paralysis, 111 
duration of, 114 
frequency of, 112 
liabilitv to, in different re- 



gions, 113 
local, 119 
prognosis of, 116 
symptoms of. 114 
time of onset of. 113 
treatment of, 116 
operative, 11 7 

laminectomy, 118 
diagnosis of. 46 
differential. 46 
congenital dislocation of 

hip. 47 
hip disease. 48 
lumbago, 46 
sacro-iliac disease, 46 
sciatica, 46 
in general, 64 

Roentgen ray in, 65 
examination in, regional, 38 

tests in, 37 
forcible correction of the de- 
formity of, 1 1 9 
Calotfs operation, 119 
selection of ca-<^ for. 1 21 
gradual correction of deform- 
ity of, 123 
Gold th wait' a method, 

123 
M'-t zger-Goldthwait ap- 
paratua for, I-'-'. 



2s 



tuberculous disease of. history 

oi patient having. 36 
later effects of deformity of, 

127 
in lower region 

characteristic attitude of. 

3S 
increased lordosis in, 39 
lateral inclination of bodv 

in. 40 
location of pain in, 40 
pelvic abscess in. 1 1 
psoas contraction in, 40 
pathology of, IS 
prognosis of, 25 
record of the case. 65 
recurrence of, 127 
relative frequency of. 22 

statistics of. 22 
secondarv deformities of, 

127 
signs of, physical, 36 

rational. 35 
statistics of aire at time of on- 
set of. 23 
results of Calot's operation, 

120 
sex, 23 

situation of disease. 23 
symptoms of, 26 
awkwardness as, 
deformity as. 28 
diagnostic. 27 
general, 31 
pain as, 27 
secondary, 30 
abscess, 30 
paralysis, 30 
stiffness as, 2s 
weakness as, 28 
thoracic region. •">! 
abscess in, 55 
attitudes in. 52 
diagnosis of, 55 

differential. 
kyphosis in. "> l 
muscular spasm in. 5 l 
respiratioD in. 52 
treatment . 66 
ambulatory supporl e in. 71 
anterior shoulder brace 

in. 7<i 
corset 8, 95 
jury mas! . 86 
plaster i 
plaster jacket 
modificat 
lor braa 
I .-nop"! i 

dm L26 

indication- for, b} recum- 



840 



INDEX. 



Spine, tuberculous disease of, treat- 
ment of special indications 

For, of different regions, 99 
mechanical, general princi- 
ples of, <)<> 
horizontal fixation in, 67 
Bradford Frame, 68 

modifications of, 69 
Lorenz apparatus for, 

(17 
Phelps' bed, 68 
wire euirasse, 68 
middle cervical region, 102 

region, 102 
occipito-axoid region, 103 
upper dorsal region, 102 
upper region, 57 

cervicodorsal junction, 60 
diagnosis of, 61 
lower cervical section, 

59 
occipito-axoid section, 
58 
symptoms of, 58 
Spine, typhoid, 134 

treatment of, 134 
variations in contour of, 223 
Splay foot. See Weak foot, 664 
Spondylitis deformans, 135 
cases of, 138 

pathology of, 136 
symptoms of, 138 

treatment of, 141 
traumatic, 132 

treatment of, 133 

Spondylolisthesis, 145 

Spondylose rhizomelique. See Spon- 
dylitis deformans, 135 
Spontaneous dislocation of hip-joint, 

393 
Sprain of ankle, 450 
chronic, 153 

t real ment of, 453 
aymptome of, 450 
t real menl of, 450 

adhesive plaster in, 451 
of wrist, 170 
chronic, 170 
Sprengel'a deformil v, 228 
s of, 229 
etiology of. 229 
treatment of, 229 
Statistics of abscess complicating tu- 
berculous disease of t he 

-pine, ]()! 

in different regions, 1 no 
in tuberculous disease of hip- 
joint. :-:7l 
Koenig's, 372 
knee-joint, U9 
of actual lengthening in tubercu- 
lous disease of knee-joint, 408 
shortening m tuberculous dis- 
oi knee-joint , 407 



Statistics of acute arthritis of infancy, 
271 
age, at incipiency of tuberculous 
disease of elbow-joint, 
461 
of knee-joint, 402 
of shoulder-joint, 458 
of wrist-joint, 465 
in lateral curvature of spine, 163 
at onset of acute anterior polio- 
myelitis, 584 
of patients having tuberculous 
disease of ankle-joint, 
441 
of bones and joints, 247 
of hip-joint, 295 
at time of onset of tuberculous 
disease of spine, 23 
of bow-leg, 553 

relative frequency of, 553 
table of, 554 
Brackett's, of atrophy in tubercu- 
lous disease of hip-joint, 308 
of causes of death in tuberculous 
disease of hip-joint, 
385 
of knee-joint, 425 
of Charcot's disease, 285 
of club-hand, 479 
of congenital dislocation at hip- 
joint, 502 
of coxa vara, 538 

of deformity resulting from tuber- 
culous disease of knee-joint, 425 
of diseases of nervous system, 583 
of distribution of disease in tuber- 
culous disease of bones and 
joints, 246 
of paralysis in acute anterior 
poliomyelitis, 585 
in cerebral paralysis of child- 
hood, 606 
Dollinger's, of retardation of growth 
in tuberculous disease of hip- 
joint, 311 
of situation of tuberculous dis- 
ease of spine, 24 
of excision of hip in tuberculous 

disease of hip-joint, 379 
of final results of excision of elbow, 
464 
in tubercular disease of knee- 
joint, 424 
of frequency of paralysis in Pott's 

disease, 112 
functional results after tuberculous 
disease of hip-joint, 387 
of knee-joint, 424 
Colmey's, of course and outcome of 
tuberculous disease of knee-joint, 
423 
of ironorrhoeal arthritis, 267 
of knock-knee, 553 

relative frequency of, 553 



INDEX. 



841 



Statistics, knock-knee, table of, 554 
of malignant disease of spine, 129 
of mortality. Koenig's. in tubercu- 
lous disease of knee-joint. 424 
in tuberculous disease of hip- 
joint. 3S4 
occupation as inducing deformity 
in lateral curvature of spine. 170 
of open operation for congenital 

dislocation of hip. 532 
of relative frequency of different 
forms of talipes, 742 
of lateral curvature of spine. 

161 
of tuberculous disease at dif- 
ferent vertebrse, 24 
of hip-joint. 295 
of spine, 22 
strength of muscles of foot, 659 
of results of arthrectomy in tuber- 
culous disease of knee-joint, 
421 
of Calot's operation, 120 
of excision in tuberculous dis- 
ease of knee-joint, 423 
of laminectomy in treatment of 

Pott's paraplegia, 118 
after-treatment of tuberculous 
disease of ankle-joint, 448 
rhachitic lateral curvature of spine, 

169 
of sex in lateral curvature of spine, 
162 
of patients with tuberculous dis- 
ease of hip-joint, 295 
of spine, 23 

of bones and joints, 247 
of side affected in tuberculoid dis- 
ease of bones and joints, 
246 
of hip-joint, 296 
of situation of disease in tubercu- 
lous disease of ankle- 
joint, 441 
of spine, 23 
of spina ventosa. 407 
table of ago at incipiency of tuber- 
culous disease of ankle-joint, 442 
of talipes, 7 11 

equinovalgus with congenital ab- 
sence of fibula, 790 
Taylor'-, of retardation of growth 
in tuberculous disease of hij>- 
joint, 312 
of tendon transplantation for relief 

of paralytic talipes, 81 5 
of torticollis, 625 
of tuberculous disease of ankle 
joint. 1 10 
elbow-joint, 160 
individual bones, 1 19 
of knee-joint. 101 

shoulder-joint, 157 
of wrist-joint, >o 1 



Statistics o\ weak foot, 669 
Strain of tendo Aclullis. 710 
Subacute osteomyelitis, 273 
Subastragaloid disease, 441 

Subcutaneous tenotomy in treatment 

of talipes. 772 
Subluxation o( wrist. 178 
etiology of, 478 
treatment of, 479 
Synovial tuberculosis at knee, 420 

treatment of, 120 
Synovitis of knee, 427 
chronic, 428 

treatment of, 428 
treatment, of, 427 
Syphilis of spine, 129 
diagnosis of, 129 
Syphilitic diseases of joints, 203 
gonorrheal arthritis, 267 
distribution of, 267 
statistics of, 267 
symptoms of, 267 
treatment of, 268 
varieties of, 268 
puerperal arthritis, 269 
treatment of, 265 



TABETIC deformity of spine, 142 
Table of functional results after 
excision of hip, 380 
Table of weight, height, and circum- 
ference of chesl in childhood, 235 
Talipes, 733 
acquired, 794 

development of deformity in, 795 
differential diagnosis from con- 
genital, 796 
etiology of, 79 1 
arcuatus." See Contracted foot, 699 
calcaneus, acquired, 80 l 

development of deformity in, 

SOI 

symptoms of. so:, 

i real men! of. 805 

operal ive, s(| 7 

Whitman's operation, 808 
Willett's operation, 808 
congenital, 788 
Talipes, congenital, anatomy of, 743 
etiology of, : 
symptoms of, 748 
t real menl of, 7 is 
cavus. St > ' out racted foot . 699 
equinovalgu -. 789 
acquired, s ' '■'> 

with congenital absence of fibula, 
790 
ft iologv of, 7'»l 
-t;it i-t if- ol . 791 

treatment of, 
equinovarus, acquired, 8 ' ' 
with congenital al ' ibia, 



842 



INDEX. 



Talip i s equinus, acquired, 796 
etiology of, 797 
prognosis of, 799 
bj mptoma of, 798 

treatment of, 799 
arthrodesis in, s <>:> 
immediate correction of de- 

fonnit v in, 801 
tonic effect of, 801 
Shaffer extension .shoe in, 800 
Talipes, etiology of, ~'MS 
forcible manual correction of de- 
formity of, 703 
infantile, treatment of, Judson's 
brace in, 75 I 
manual correctioo in, 760 
mechanical, 750 
plaster bandage in, 751 
principles of, 749 
rectification of deformity in. 

750 
retention brace in, 758 
splints and braces in, 754 
Taylor 1 trace in, 758 
tenotomy in, 75G 
plantaris. See Contracted foot, 699 
rapid correction of deformity of, 

763 
secondary deformities of, 770 
and spina bifida, 793 
statistics of. 7 11 

relative frequency of different 
forms of, 742 
treatment of, division of the tendo 
Achillis in, 77.-5 
open method, 773 
malleotomv in, 772 
by method of Julius Wolff, 774 
neglected, 761 

operation- on the bones in, 781 
astragalectomy, 781 
cuneiform osteotomy, 782 
operations on bones in, second- 
ary osteotomy, 783 
by osteoclasts, 778 
* Grattan method, 778 
Phelps* operation, 778 
-imple mechanical rectification 
of deformity in walking chil- 
dren. 7s:; 
subcutaneous tenotomy in, 772 
by Thomas 1 method. 776 
by wrench.-. 77»> 
valgus, simple, acquired, 814 

7:; l 
varus, congenital, 7s7 
wit h congenita] absence of tibia, 
792 

8, tuberculous disease of, i p» 
t real oaenl <-: . 1 19 
Taylor brace in treal oaenl of in 
talipes, 758 
of tuberculous disease of spine, 



Taylor brace in treatment of tubercu- 
lous disease of spine, 
application of, 77 
measurements for, 76 
Taylor head support in treatment of 
tuberculous disease of spine, 81 
median abduction brace in treat- 
ment of tuberculous disease of 
hip-joint, 364 
method of traction in tuberculous 

disease of hip-joint, 329 
statistics of retardation of growth 
in tuberculous disease of hip, 312 
Tendo Achillis, division of, in treat- 
ment of talipes, 773 
strain of, 716 
Tendon splicing, 823 

and arthrodesis, 824 
transplantation in combination 
with other procedures, 822 
relief of paralytic talipes, 815 
the operation, 820 
modifications of, 821 
■ selection of muscles for, 
817 
statistics of, 815 
in treatment of acute anterior 
poliomyelitis, 602 
Tenosynovitis, 454 
acute, at wrist, 470 
chronic, at wrist, 471 
treatment of, 455 
tuberculous, 455 
Tenotomy in treatment of infantile 

talipes, 756 
Teschner's exercises in treatment of 

lateral curvature of spine, 187 
Thomas' brace in treatment of knock- 
knee, 570 
of tuberculous disease of hip- 
joint, 339 
modifications of, 343 
collar in treatment of tuberculous 

disease of spine, 96 
knee brace in treatment of tubercu- 
lous disease of knee-joint, 414 
method of reduction of deformity 
in tuberculous disease of hip- 
joint, 342 
of treatment of talipes, 776 
treatment of tuberculous disease of 
hip-joint, 338 
for weak foot, 696 
Tibia, anterior displacement of. See 

Congenital genu recurvatum, 434 
Toe-joint, painful great, 719 
Toes, overlapping, 727 
Torticollis, 625 
acquired, 631 
causes of, 633 
varieties of, 631 
acute, 631 

etiology of, 632 
symptoms of, 633 



INDEX. 



843 



Torticollis, acquired, varieties of acute, 
treatment of, 640 
congenital. 626 
etiology of, 629 
pathology of, 630 
Torticollis, congenital, diagnosis of, 
635 
with diphtheritic paralysis. 646 
irregular forms of, 645 

cervical opisthotonos. 646 
ocular. 646 
paralytic. 645 

pathology of, 641 
psychical, 646 
rhachitic, 646 
spasmodic, 640 
etiology of, 641 
prognosis of, 642 
treatment of, 642 

description of operation for, 

643 
operative. 642 
statistics of, 625 
treatment of. 636 

by manipulation, 636 
by the open method, 637 
overcorrection of deformity in. 

638 
by subcutaneous tenotomy, 637 
Traction hip splint for tuberculous 
disease of hip-joint, 
327 
application of, 331 
straps for tuberculous disease of 
hip-joint, 329 
Traumatic coxa vara, 548 
in adult life, 551 
treatment of, 550 
equinovalgus, 814 
separation of the epiphysis of head 
of femur, 550 
Traumatic spondylitis, 132 
treatment of, 133 
valgus, 814 
Treatment of abscess complicating 
tuberculous disease 
of spine, 108 
aspiration in, 110 
injections in, 110 
in tuberculous disease of hip- 
joint. 374 
exploratory operation in, 
376 
of knee-joint . 420 
of achillobursitis, 71 \ 
of acquired calcaneo valgus, SI 2 
calcaneovaruB, 812 
luxation of clavicle, 233 
talipes calcane is, 80 5 
equinus, 799 
of acute acquired torticollis, 631 
anterior poliomyelitis, 595 
arthriti- of infancy, 271 



Treatment of acute epiphysitis at hip- 



131 



oi 



disease of 
369 



joint, 392 

osteomyelitis of spine 
of anchylosis, 286 

forcible correction in, 2SS 

passive motion m, 288 

X-ray in, 289 
of anterior bow-leg, 582 
of anteroposterior deformities 

spine, 227 
of arthritis complicating infectious 
diseases, 269 

deformans, 397 
Bier's, of tuberculous 

joints, 259 
of bilateral hip disease, 
of bow-leg, 558 
of calcaneobursitis, 716 
of cerebral paralysis of childhood, 

612 
of Charcot's disease, 285 
of chondrodystrophia, 494 
of chronic sprain of ankle, 453 

synovitis of knee, 428 
of club-hand, 481 
of congenital dislocation at hip- 
joint, 513 
of shoulder, 472 
talipes, 748 
of contracted fingers, 484 

foot, 702 
of coxa vara, 545 
of displaced semilunar cartilage, 

432 
of displacement of peronoi tendons, 

727 
of Dupuytren's contraction, 185 
during stage of recovery of tuber- 
culous disease of hip-joint, 363 
of elongation of ligamentum patel- 
la, 438 
of flat chest, 230 
of general contraction- al knee, 

439 
of genu varum, 578 
of gonorrhoea! arthritis, 268 
of haemophilia. 2 s ". 
of hallux rigidus, 71 ( .) 
valgus, 723 
yarns. 721 
of hammer-toe 
ol hemiplegia, 612 
of hysterical scoliosis, 621 

spine, I 1 1 
of iliopsoas bursitis, 396 
of infant ilf scorbutus, 195 

talipes, 750 
of infectious arthritis of Bpine, 

of knock-knee, 561 

of lateral cun b pine, i s i 

duration ol . 221 

185 201 



-I! 



INDEX. 



Treatment of lateral curvatureof spine, 
exercises in, Tesehner's, 
187 
for muscle building, 209 
forcible correction of de- 
formity in, 217 
general, 221 
high shoe in, 221 
posture in, L85 
Volkmann scat in, 221 
malformations of knee, 435 
mechanical, of tuberculous disease 
of hip-joint, '.Y2~ 
of spine, ambulatory sup- 
ports in, 74 
anterior shoulder brace, 

76 
application of, in recum- 
bency. 89 
jury mast, 86 
plaster corset as, 92 
plaster jacket as, 82 
Taylor brace as, 74 
head support, 81 
Thomas' collar, 96 
Weigel's corset as, 95 
general principles of, 66 
horizontal fixation in, 67 
Bradford frame for, 68 
Lorenz apparatus for, 

67 
Phelps" bed for, 68 
wire cuirasse for, 68 
of metatarsalgia, 710 
of neglected talipes, 761 
of neurol ic spine, 143 
of obstet lical paralysis, 474 
operative, of tuberculous disease of 
ankle-joint, 447 
of elbow-joint, 462 

of shoulder- joinl , 460 
osteo-arthritis, 279 
of hip-joint, 397 
of knee, 128 
of osteomalacia, 197 
oi paralysis complicating tubercu- 
lous disease of spine, 

1 16 
operat ive. ] 1 7 

Laminectomy, 118 
statistics, results, 118 
• ill 
periari hrit is of shoulder, 169 
geon chest, 231 
of plantar neuralgia, 71 7 

epatellar bur-it is of knee, 429 

pretibial bursit is, 130 

lohypertrophic muscular 
■ ysis, 619 
current dislocation of shoulder. 

■ line, L33 
rhachitis, 191 
of rheumatoid arthritis, 282 



Treatment of rigid weak foot, 690 
of rudimentary or absent patella,. 
4,36 

of sacro-iliac disease, 147 

of sinuses in tuberculous disease of 

hip-joint, 375 
of slipping patella, 437 

operative, 437 
of snapping knee, 439 
of spasmodic torticollis, 642 
of spondylitis deformans, 141 
of sprain of ankle, 450 
of Sprengel's deformity, 229 
of subluxation of wrist, 479 
of svnovial tuberculosis at knee, 

420 
of synovitis of knee, 427 
of talipes equinovalgus with con- 
genital absence of fibula, 792 
of tenosynovitis, 455 
of torticollis, 636 
of traumatic coxa vara, 550 

spondylitis, 133 
of traumatisms at hip-joint, 391 
of trigger finger, 484 
of tuberculous disease of ankle- 
joint, 446 
of elbow-joint, 461 
of hip-joint, 325 
of joints, 256 

carbolic acid in, 258 
by drugs, 257 
by local application, 258 
X-ray in, 258 
of knee-joint, 409 
of shoulder-joint, 459 
of spine, 66 

indications for, by recum- 
bency, 98 
special, at different re- 
gions, 99 
lower region, 100 

dorsal region, 101 
middle region, 102 

cervical region, 102 
occipito-axoid region, 103 
upper dorsal region, 102 
of tarsus, 449 
of wrist-joint, 465 
of typhoid spine, 134 
of varieties of rigid weak foot, 696 
of weak foot, 682 
of webbed fingers, 483 
Trigger finger, 483 
etiology of, 483 
treatment of, 484 
Tuberculosis of bones and joints, 243 
distribution of disease in, 246 
statistics of, 246 
age, 247 
sex, 247 

side affected, 246 
etiology of, 243 
local predisposition to, 245 



IXDEX. 



845 



Tuberculosis of bones and joints, mode 
of infection in. 243 
pathology oi. 248 
perforation of joint in. 250 
latent. 243 

synovial, at knee. 420 
treatment of, 420 
Tuberculous disease of ankle-joint, 
440 
deformity of, 443 
diagnosis of, 444 
pathology of, 440 
physical examination in, 443 
prognosis of, 44S 
statistics of, 440 
age, 441 
results. 44S 

situation of disease. 441 
table of age at inripiency, 
442 
subastragaloid disease, 4-14 
symptoms of, 442 
treatment of, 446 
operative, 447 
reduction of deformitv in, 
446 
of astragaloscaphoid joint, 440 
Tuberculous disease of elbow-joint. 
460 
excision of elbow in treatment 
of, 464 
statistics of final results. 
464 
pathology of, 460 
prognosis of, 462 
statistics of, 460 

age at incipiency of. 461 
symptoms of, 461 
treatment of, 461 
operative, 464 
reduction of deformitv in, 
462 
Tuberculous disease of hip-joint, 291 
abscess in, 371 

significance of, 373 
statistics of, 371 
Koenig's, 372 
treatment of, 374 

exploratory operations in, 
376 
actual lengthening of limb in, 
313 
shortening of limb in, 309 
in adult. 371 
atrophv in. 307 

Brackett's statistics of, 308 
bilateral, 369 

treatment of, 369 
change- in contour of hip in. 

300 
combined with disease of other 

part-. 3 70 
correction of deformity l»\ 
femoral osteotome 



Tuberculous disease of hip-joint, de- 
formities of other parts 
caused by, 389 
details of 1000 cases of, 324 
diagnosis of, differential, 319 
anterior poliomyelitis in. 

319 
congenital dislocation of 

hip, 322 
coxa vara in, 321 

traumatic, in, 321 
disease of bursa? about 

joint in, 321 
epiphysitis in, 320 
extra-articular disease in, 

320 
growing pains in, 319 
hysterical joint in. 322 
infectious arthritis in, 320 
local injury in, 319 
local irritation in, 319 
osteo-arthritis of the hip 

in, 320 
"Pott's disease in, 321 
rheumatism in, 320 
sacro-iliac disease in, 321 
scurvy in, 320 
synovitis in, 319 
X-ray as means of, 322 
distortion of the limb in. 301 
apparent lengthening, 301 
shortening, 302 
etiology of. See 243 
examination in, method of, 
313 
physical, 314 
excision of hip in, 377 

Koenig's met hod of, 377 
statistics of, 379 

tabic of functional re- 
sults, 380 
general symptoms of, 31 3 
debility, 313 
fever. 313 
history of case of, 313 
in infancy, 370 
Koenig's stal isl ics of, 30 I 
local signs of, 31 s 
measurements of, 31 5 
method of estimating degree of 
distortion of limb 
in, 316 
Kingsle} 'a table, -''.1 8 
Lovett'a table, 316 

cording ca 
formula used, 
mortality in, statistic! 

causes of deal b, 
n.it ural cup 
pathology of, 291 
prognoe 

. function 

387 
i functions 



846 



INDEX. 



Tuberculous disease of the hip-joint, 

reduction of deformity in 

resistant cases of, 3X1 

relative frequency of, 295 
-tat istics of, 295 

retardation of growth in, 311 
Do4 linger* s statistics of, 

311 
Taylor's statistics of, 312 

sinuses in, 375 

treatment of, 375 
statistics of age in, 295 
of sex in, 295 
side affected, 296 
symptoms of, 296 
" limp as, 298 
night cry as, 297 
pain as, 297 
stiffness as. 298 
treatment of, 325 

application of plaster spica, 

345 
during stage of recovery, 363 
immediate reduction of de- 
formity in, 348 
Judson's perineal crutch in, 

365 
Lorenz's spica in, 347 
mechanical, 327 

application of traction 

splint in, 331 
high shoe in, 331 
perineal bands in, 331 
splinting in, 327 
Taylor's method of trac- 
tion in, 329 
traction in, 327 
hip splint for, 327 
straps for, 329 
by plaster bandage, 345 
practical combination trac- 
tion, splinting, stilting, 
356 
reduction of deformity by 
Thomas' method, 342 
by traction brace in, 

333 
by weights and pulleys, 
350 
lateral traction in, 

353 
Marsh's appliance 
for, 351 
relal Lve efficiency of traction 
hip splint in, 334 
and spknl Lng, 35 1 
Taylor's median abduction 

brace, 364 
Thomas'. 338 
brace in, 339 
modifical ions of, 3 13 
Tuberculous disease of individual 
bones, 1 1'» 
statist ics of. 1 19 



Tuberculous disease of bones and 
joints, 241 
arborescent synovial, 252 
caries sicca, 253 
diagnosis of, 256 
lipoma arborescens, 252 
other forms of, 251 
prognosis in, 254 
repair in, 254 
rice bodies, 253 
septic infection in, 253 
treatment of, 256 
Tuberculous disease of knee-joint,»399 
abscess in, 419 
statistics of, 419 
treatment of, 420 
actual lengthening of limb in, 
407 
statistics of, 408 
shortening of limb in, 407 j 
statistics of, 407 
diagnosis of, 408 
differential, 408 
- Charcot's disease in, 409 
haemophilia in, 408 
hysterical joint in, 409 
infectious arthritis in, 409 
injury in, 408 
osteo-arthritis in, 409 
rheumatism in, 409 
rheumatoid arthritis in, 

409 
sarcoma in, 409 
synovitis in, 408 
distortions of, primary 404 

secondary, 405 
etiology of, 401 
operations for relief of final de- 
formity, 423 
pathology of, 399 
prognosis of, 423 

statistics, course, and out- 
come of, 423 
Gibney's, 423 
of results, 424 
statistics of, 401 

age at incipiency, 402 
symptoms of, 402 
synovial tuberculosis, 420 

treatment of, 420 
treatment of, 409 
accessory, 417 

Bier's treatment of, 418 
cautery as, 417 
ichthyol ointment as, 417 
X-ray as, 417 
amputation, 423 
arthrectomy in, 420 
results of, 421 
statistics of, 421 
Billroth splint in, 413 
during convalescence, 418 
excision in, 422 
results of, 423 



INDEX. 



847 



Tuberculous disease of knee-joint, : 
treatment of, excision in, 
statistics of , 423 
forcible correction by reverse 

leverage, 412 
mechanical. 414 

caliper brace in. 417 
Thomas knee brace in. 414 
operative intervention in, 

419 
plaster bandage in, 411 
reduction of deformity in,410 
traction in. 412 
Tuberculous disease of shoulder-joint, 
457 
pathology of, 457 
prognosis of, 4(30 
statistics of, 457 

age at incipiency of, 458 

symptoms of, 458 

treatment of, 459 

operative, 460 

Tuberculous disease of spine, 17 

abscess in different regions, 106 
treatment of, 108 
aspiration in, 110 
injections in, 110 
complications of, 104 
abscess, 104 

statistics of, 104 
paralysis, 111 
duration of, 114 
frequency of, 112 
liability to in different re- 
gions, 113 
prognosis of, 116 
symptoms of, 114 
time of onset of, 113 
treatment of, 116 
local, 119 
operative, 117 

laminectomy, 118 
correction of deformity of, for- 
cible, 119 
Calot's operation, 119 
selection of cases for, 
121 
gradual, 123 

Goldth wait's method, 

123 
Metzger - Goldthwail 
apparatus for, 123 
diagnosis of, differential, 16 
congenital dislocation of 

hip in, 17 
hip disease in, IS 
lumbago in, 16 
sacro-uiac disease in, 16 
scial ica in, 16 

-train of back in. 16 

aeral, 61 
Roentgen ray in, 65 
examination in, regional, 38 

37 



Tuberculous disease of spine, history 
of patient Inning. 36 
later effects of deformity of, 

127 
Tuberculous disease of spine in lower 
region, 38 
characteristic attitude of, 

3S 
increased lordosis in, 39 
Lateral inclination of body 

in, 40 
location of pain in, 10 
pelvic abscess in, I 1 
psoas contract ion in, 40 
pathology of, 18 
physical signs of, 36 
prognosis of, 25 
rational signs of, 35 
record of the case, 65 
recurrence of, 127 
relative frequency of, 22 

statistics of, 22 
secondary deformities of, 

127 
statistics of age at time of on- 
set, 22 
Dollinger's, 24 

of relative frequency at 
different vertebra*, 24 
of results of Calot's opera- 
tion, 120 
of sex, 23 

of situation of disease, 23 
symptoms of, 26 
awkwardness as, 28 
deformity as, 28 
diagnostic, 27 
general, 31 
pain as, 27 
secondary, 30 
abscess, 30 
paralysis, 30 
stiffness as, 28 
weakness as. 28 

Tuberculous disease of spine, thoracic 

region, 5 I 

abscess in, 55 

attitudes in, 52 
diagnosis of, 55 

different ial, 56 

kyphosis in, 5 I 
muscular spasm in, 5 I 
respiral ion in 

treatment ol 

duration of, 126 
indications for, by recum- 
benc 
special, of differ* n1 re- 
gions. 99 
of lower dorsal, 101 

ion, l oo 
mechanical, 67 
ambulator) mp| ■ 
71 



848 



INDEX. 



Tuberculous disease of spine, treat- 
ment 01, mechani- 
cal,ambulatory sup- 
ports in, anterior 
shoulder brace, 7(i 

plaster, 02 
Wiegel's, 95 
jury mast , 86 
plaster jacket, 82 
application of, in 
recumbency. 89 
modifications of, 93 
Taylor brace, 74 

head support, 81 
Thomas collar, 96 
general principles of, 66 
horizontal fixation in, 67 
Bradford frame, 68 

modifications of, 69 
Lorenz apparatus. 07 
Phelps' bed, 68 
wire cuirasse, 68 
Tuberculous disease of spine of middle 
cer\ ical region, 102 
of middle region, 102 

of occipito-axoid region, 103 
of upper dorsal region, 102 
of upper region, 57 

cervicodorsal junction, 60 
diagnosis of, 61 
lower cervical section, 59 
occipito-axoid section, 58 
symptoms of, 58 
Tuberculous disease of tarsus, treat- 
ment of, 449 
Tuberculous disease of wrist-joint, 
464 
prognosis of, 466 
statistics of, 464 

age at incipiency, 165 
symptoms of, 465 
treatment of, 465 
Tumor albus. See Tuberculous dis- 

oi knee-joint, 399 
Typhoid spine, 1 •"> l 
treatmenl of, 134 



U 



NIL \Tl.i:.M. knock-knee, 565 



VALG< >CAVUS, 789 
.-. Bimple acquired, 814 
is, traumatic, 81 1 
Vertebra, absence of. 230 

Volkmanrj seal in treatment of lateral 
curvature ol -pine, 221 



Wi; \K i..ot. 664 
anatomy oi . 66 1 
Weak foot in ehildl 

ptoms of, 



Weak foot in childhood, diagnosis of, 
672 
etiology of, 669 
exl reme types of, 676 

persistent abduction in, 676 
pes planus, 676 
irregular forms of, 680 
limitation of motion and muscu- 
lar spasm in, 676 
pathology of, 668 
rigid, 690 

treatment of, 690 

forcible overcorrection in, 

690 
manipulation in, 693 
varieties of, 695 
treatment of, 696 
operative, 697 

arthrodesis in, 697 
plaster strapping in, 696 
Thomas', 696 
Weak foot, statistics of, 669 
symptoms of, 670 
treatment of, 682 
1 attitudes in, 683 
brace in, 685 

construction of, 685 
exercises in, 684 
shoe in, 682 
support in, 684 
varieties of, 675 
Webbed fingers, 482 
etiology of, 483 
treatment of, 483 
White swelling. See Tuberculous dis- 
ease of knee-joint, 399 
Whitman's operation in treatment of 

acquired talipes calcaneus, 810 
Willett's operation in treatment of 

acquired talipes calcaneus, 808 
Wire cuirasse for horizontal fixation 

in treatment of Pott's disease, 68 
Wolff's law, 235 

treatment of knock-knee, 574 
Wrist, acute tenosynovitis at, 470 
chronic tenosynovitis at, 471 
congenital deformities at, 479 
-joint, tuberculous disease of, 464 
sprain of, 470 
chronic, 470 
subluxation of, 478 
etiology of, 478 
treatment of, 479 
tuberculous disease of, 464 
prognosis of, 466 
statistics of, 464 

age at incipiency, 465 
symptoms of, 465 
treatment of, 465 
Wryneck. See Torticollis, 625 



X 



RAY as accessory in treatment 
of tuberculous disease of knee- 
joint, 417 









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